Handbook of Dermatology

Handbook of DermatologyA Practical Manual

SeconD eDition

Margaret W. Mann, MDAssociate Professor and Director of Aesthetic DermatologyUniversity Hospitals, Case Western School of MedicineCleveland, OH, USA

Co-FounderInnova DermatologyHendersonville, TN, USA

Daniel L. Popkin, MD PhDAssistant Chief of Dermatology, Louis Stokes VA Medical CenterAssistant Professor of DermatologyUniversity Hospitals, Case Western School of MedicineCleveland, OH, USA

Co-FounderInnova DermatologyHendersonville, TN, USA

This edition first published 2020© 2020 by John Wiley & Sons Ltd

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The rights of Margaret W. Mann and Daniel L. Popkin to be identified as the authors of editorial in this work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication DataNames: Mann, Margaret W., author. | Popkin, Daniel L., author.Title: Handbook of dermatology : a practical manual / Margaret W. Mann, Daniel L. Popkin.Description: Second edition. | Hoboken, NJ : Wiley Blackwell, 2020. | Preceded by Handbook of dermatology /

Margaret W. Mann ... [et al.]. 2009. | Includes bibliographical references and index. | Identifiers: LCCN 2019003278 (print) | LCCN 2019004180 (ebook) | ISBN 9781118408537 (Adobe PDF) |

ISBN 9781118408520 (ePub) | ISBN 9781118408544 (pbk.)Subjects: | MESH: Skin Diseases–diagnosis | Skin Diseases–therapy | Dermatologic Agents–therapeutic use |

HandbookClassification: LCC RL74 (ebook) | LCC RL74 (print) | NLM WR 39 | DDC 616.5–dc23LC record available at https://lccn.loc.gov/2019003278

Cover Design: WileyCover Images: © STEVE GSCHMEISSNER/SCIENCE PHOTO LIBRARY/Getty Images

Set in 7.5/9.5 Frutiger by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1

Dedication

This second edition is dedicated to our son Samuel. Without you, completing this second edition would have been so much faster and less fun.

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Preface, xvAcknowledgments, xvii

Part 1 General Dermatology, 1

Common Work-uPs, signs, And mAnAgement, 3dermatologic differential Algorithm, 3direct immunofluorescence (dif), 3

False positive/negative diFs, 3Workup Quick reference orders, 4Acne, 6Alopecia Workup, 7

telogen effluvium, 10Androgenic alopecia, 10Alopecia areata, 11other alopecia treatments, 12

Aphthosis Workup and treatment, 13dermatologic signs, 15Folliculitis, 21melasma, 22

immunology And immunologiC diseAse, 24lupus erythematosus, 24Autoantibody, 26

sensitivities and specificities, 26in connective tissue diseases, 28Anti‐nuclear antibodies, 29AnCA (Anti‐neutrophil cytoplasmic antibodies), 30treatment of AnCA‐associated vasculitis, 30

Vasculitis, 31small vessel vasculitis, 31medium vessel vasculitis, 33large vessel vasculitis, 34

Cryoglobulinemia, 34Bullous disorders, 36

intracorneal/subcorneal, 36intraepidermal, 36suprabasilar, 37subepidermal with little inflammation, 37epidermolysis bullosa, 39major bullous diseases – clinicopathologic findings, 42

Contents

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Complement, 46Angioedema and complement levels, 46Complement deficiencies, 47

gVHd, 47HlA associations, 48th profiles, 50

sPeCiAl sites: glAnds, nAil, Bone, muCosA, 51glands, 51nail terminology, 53disorders or drugs associated with nail, bone, or ocular findings, 57genital ulcers, 67

inFeCtion And inFestAtions, 68Fungal disease / mycoses, 68

laboratory tests, 68superficial mycoses, 68Cutaneous mycoses, 69subcutaneous mycoses, 71systemic mycoses, 73opportunistic mycoses, 75

Viruses and diseases, 78Human papilloma virus, 79other viral diseases, 80

infections/Bugs, 83Vector‐borne diseases, 83Creatures in dermatology, 88

ContACt And PlAnt dermAtitis, 93Patch testing, 93Common contact allergens, 95Allergic vs. irritant contact dermatitis, 104Allergens – location specific, 105Features suggestive of specific irritant/toxin, 106Plants and dermatoses, 106

tumors snd inFiltrAtes, 109Cutaneous t Cell lyphoma, 109Cutaneous B‐cell lymphoma, 113leukemia cutis, 113monoclonal gammopathies in dermatology, 114tumors and gene associations, 115For melanoma, BCC, and sCC, see skin Cancer, 221

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systemiC And metABoliC diseAses, 117Amyloidoses, 117Histiocytosis, 119Xanthomas, 124Hyperlipoproteinemias, 125Vitamin deficiencies/Hypervitaminoses, 127

PediAtriC And PregnAnCy dermAtology, 131Vascular tumors and malformation, 131infantile Hemangioma (iH) management, 132neonatal vesiculopustular eruptions, 137genodermatoses, 142

Chromosome abnormalities, 171disorders of cornification, 171disorders of connective tissue, 175

ehlers–danlos, 177Collagen types, 178

disorder of hair, nail, ectoderm, 179tumor syndromes, 185disorders of vascularization, 186disorders of metabolism, 189Porphyrias, 191disorders of pigmentation, 193immunodeficiency syndromes, 196miscellaneous, 198

dermatoses of pregnancy, 200

dermosCoPy And dermAtoPAtHology, 202dermoscopy, 202dermatopathology, 206

Histochemical staining, 206immunohistochemical staining, 207Pathologic bodies, 210Cysts, 214other derm path buzzwords, patterns, ddx, 215

Part 2 Surgical and Cosmetic Dermatology, 219

surgiCAl dermAtology, 221skin cancer, 221

surgical margin guidelines, 221indication for mohs micrographic surgery, 222melanoma, 223squamous cell carcinoma (sCC), 228

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Prophylactic antibiotics and antivirals, 230guideline for Prophylactic antibiotics, 230Algorithm for antibiotic prophylaxis, 231guideline for prophylactic antivirals, 231Antiseptic scrubs, 232

Anesthetics, 234dose calculation, 234standard formula for buffered lidocaine, 234tumescent anesthesia, 234topical anesthetic (see drug section pg. 316), 235Adverse reaction to local anesthetics, 235local anesthetic, 236

nerve blocks, 237surgical anatomy, 237

Anatomy of the face, 237danger zones in surgery, 242dermatomal distribution of sensory nerves, 244Anatomy of the lower extremity venous system, 245Anatomy of the nail, 246

Cutaneous reconstruction, 247undermining depths in reconstruction, 248reconstruction algorithm: stAirs, 248

sutures, 260Absorbable, 260nonabsorbable, 261suture removal time, 262

electrosurgery, 262Wound healing, 262Wound dressing, 263

CosmetiC dermAtology, 264laser, 264

laser fundamentals, 264laser treatment of tattoo pigment, 266Photoinduced eye injury, 267laser wavelength, depth of penetration and the electromagnetic spectrum, 268Absorption spectra of major skin chromophores, 268

Photodynamic therapy, 269Photosensitizer properties and options, 269Pdt Protocol, 270

uV spectrum, 271uV spectrum and wavelengths, 271uVB protection vs sPF, 272

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uV protection measurements, 272uV associations/specificities, 273

glogau wrinkle scale, 273Fitzpatrick skin type, 274Chemical peels, 274

Pre‐peel consideration, 274Peeling agents, 275

Botulinum toxin, 277injectable for adipolysis, 280Fillers, 281

Protocol for vascular occlusion from fillers, 288Venous disease treatment, 288

Vein treatment algorithm, 288sclerotherapy, 289Preparing dilution of sclerosants, 290CeAP classification for venous disease, 292Venous clinical severity score, 292

Part 3 Drugs and Therapies, 293

medication Quick reference, 295topical steroids classified by strength, 295nonsteroidals, 297Commonly used drugs in dermatology, 297

systemic medications, 302Antimalarials, 302immunosuppressive agents, 303systemic retinoids, 306Biologics, 307

general reference, 310metric measurements, 310dose calculations, 310topical medication dispensing and absorption, 310Corticosteroid dosage equivalence, 311

Acne – topical, 311Antibiotics/antimicrobial, 311keratolytics, 312retinoids, 313others, 313

Acne – oral, 314Antibiotics, 314retinoids, 315others, 315

Analgesics, 315Anesthetics – topical (see also topical anesthetic pg. 235), 316

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Anesthetics – topical compounded, 316Antibiotics, 316

topical/antiseptic, 316systemic, 317Preoperative prophylaxis, see pg. 230Postoperative skin infection, 319sensitivity, 321regimens, 322stds, 323

Antifungals, 324topical, 324oral, 325Antifungal regimens, 327

Candidal infection, 327Pityrosporum folliculitis, 327onychomycosis, 327tinea versicolor (Malassezia), 328tinea capitis, 328tinea corporis, 328tinea pedis, 329

Antiparasitics, 330scabies, 330lice, 330

Antivirals, 331HsV, 331Herpes zoster/VZV, 333genital warts, 333Verruca vulgaris, 334molluscum, 334

Antihistamines, 334sedating, 335nonsedating, 335H2‐blockers, 335

Antipruritic, 336topical, 336oral, 336

Anxiolytics/sedation, 338Benzodiazepines, 338Antihistamines , 339

Bleaching Agents/depigmenting Agents, 340Hair, 341

Alopecia – androgenic, 341Alopecia – areata, 341Hypertrichosis, 342Hypotrichosis – eyelash, 342

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Hyperhidrosis, 342Psoriasis, 343

topical agents, 343tar, 343Anthralin/dithranol, 343systemic agents, 343 (see also systemic medications pg. 306)

rosacea, 344Antibiotics/antimicrobial – topical, 344keratolytics, 344Vasoconstrictor, 344other, 344Antibiotics – systemic, 344

seborrheic dermatitis, 345skin Cancer – topical and oral Chemotherapy, 345

Actinic keratoses (Ak), 345Basal cell carcinoma (BCC), 346CtCl, 346melanoma, 347

Vasoactive/Antiplatelet Agents, 347Vitamins/nutritional supplements, 348Wound Care, 348miscellaneous meds, 348Cytochrome P‐450 interactions, 349Pregnancy Categories of Commonly used dermatologic Agents, 350Common dermatologic drugs and teratogenic effects, 351dermatologic drugs reportedly Associated with Contraceptive Failure, 352drug eruptions, 352Chemotherapeutic Agents and skin Changes, 355

Antidote to extravasation of chemotherapeutic agents, 358uV light treatment, 359

uVA/uVB dosing, 359nBuVB dosing, 359PuVA, 359

toxic epidermal necrolysis (ten) Protocol, 361diagnosis of ten, 361triage algorithm for ten patients, 362treatment for all ten patients, 363Appendix i American Burn Assocation Burn Center referral

Criteria 364Appendix sCorten score, 365Appendix iii iVig, 365Appendix iV Further reading for ten/sJs, 366

index, 367

Color plate section can be found facing page 206

xv

Welcome to the second edition of The Handbook of Dermatology: A Practical Manual, a pocket guide designed for practicing dermatologists, dermatology residents, medical students, nurses, health care providers, and physicians in other fields who may be interested in dermatology.

New to second edition: We appreciate thoughtful feedback from our readers resulting in extensive revisions including the following: Part 1 sections were reorganized so that information could be found more quickly and intuitively; many sections were added including Workup Quick Reference Table, Melasma Workup and Management Algorithm, Propranolol, Contact Dermatitis, and Dermatologic Signs and Dermoscopy; all sections were updated to reflect new gene discoveries and other interval advancements. Part 2 includes updated fillers and toxins, UV and sunscreen updates, peeling agents, and a venous disease section. In Part 3, Drugs and Therapies was extensively updated.

Our first edition was created and edited by graduating residents at Washington University School of Medicine, Division of Dermatology. Our handbook started as an in‐house resident handbook. Our goal was to compile and consolidate need‐to‐know dermatologic information for daily use in both patient care and resident and fellow education. As such, it represents the indispensable pocket‐sized quick reference which we had wanted during our training and which we now use in our practices.

Currently, there are multiple in‐depth dermatology textbooks and atlases, most of which are too bulky to be carried around in the clinic. Our manual concisely presents data in outline, bullet‐point, and table formats such that information is manageable and easily retrievable. The compact design is lightweight, allowing information to be accessible in seconds during clinics, facilitating patient care.  We have tried to balance space limitations with the need to cover a subject in sufficient detail.

Our manual has three main sections – medical dermatology, surgical dermatology, and pharmacology/treatment. Each section is designed to give the reader concise information for patient care. The content is up‐to‐date, comprehensive yet succinct. In addition to core material, we sought to consolidate the information which we found ourselves most often looking up, which our attendings most often quizzed us on, and which were most emphasized on the dermatology board exam. The manual consolidates the essential algorithms, protocols, guidelines, staging, and

Preface

xvi

scoring systems of dermatology. Each section is designed for easy reference, with tabular and graphic information throughout. The diseases covered are those which we most often encountered in clinic, on call, during morning conferences, and on board exams.

We hope you will find this manual helpful to you in providing care to your patients. We welcome your input as this manual continues to evolve.

xvii

We thank Michael McBride for his assistance in updating Part 1 General Dermatology sections and Part 3 Drugs and Therapies.

Special thanks to Drs. David Berk and Susan Bayliss, who helped make the first edition possible; without you, this book would never have happened. Finally, we wish to thank the many people who have inspired us to write this book and supported us in our careers–our mentors, our colleagues and especially the residents and students we have had the pleasure of working with–for this book is written for you.

Acknowledgments

Handbook of Dermatology: A Practical Manual, Second Edition. Margaret W. Mann and Daniel L. Popkin. © 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.

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General Dermatology

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COMMON WORK-UPS, SIGNS, AND MANAGEMENT

Dermatologic Differential Algorithm

Courtesy of Dr. Neel Patel

1. Is it a rash or growth?2. If it is a rash, is it mainly epidermal, dermal, subcutaneous, or a combination?3. If the rash is epidermal or a combination, try to define the

characteristics of the rash. Is it mainly papulosquamous? Papulopustular? Blistering?After defining the characteristics, then think about causes of that type of rash: CITES MVA PITA:Congenital, Infections, Tumor, Endocrinologic, Solar related, Metabolic, Vascular, Allergic, Psychiatric, Latrogenic, Trauma, Autoimmune. When generating the differential, take the history and location of the rash into account.

4. If the rash is dermal or subcutaneous, then think of cells and substances that infiltrate and associated diseases (histiocytes, lymphocytes, mast cells, neutrophils, metastatic tumors, mucin, amyloid, immunoglobulin, etc.).

5. If the lesion is a growth, is it benign or malignant in appearance? Think of cells in the skin and their associated diseases (keratinocytes, fibroblasts, neurons, adipocytes, melanocytes, histiocytes, pericytes, endothelial cells, smooth muscle cells, follicular cells, sebocytes, eccrine cells, apocrine cells, etc.).

Direct Immunofluorescence (Dif)

Diseases Where to biopsy

LE, MCTD, PCT, LP, vasculitis Erythematous border of active lesion/involved skin (avoid old lesions, facial lesions, and ulcers)

Pemphigus group, pemphigoid group, linear IgA

Erythematous perilesional skin (avoid bullae, ulcers, and erosions)

DH Normal‐looking perilesional skin (0.5–1 cm away)

Lupus band Uninvolved, non‐photoexposed skin (buttock)

Source: http://www.mayoclinic.org/dermatology‐rst/immunofaqs.html

False positive/negative DIFs:False negative in BP: (i) low yield of biopsy on distal extremity (esp. legs) (controversial) and (ii) predominantly IgG4 subclass of auto‐antibody (poorly recognized on DIF)

False positive in LE: chronically sun‐exposed skin of young adults

To increase DIF yield: transport in saline (reduces dermal background) – cannot do DIF on formalin‐fixed specimen

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Workup Quick Reference Orders (guided by clinical presentation)

Acanthosis nigricans CBC/CMP, lipid panel, HgA1C, TSH, CEA, LH/FSH

Alopecia(see “Alopecia Workup, p. 6–9 for further details)

CBC/CMP, Fe/TIBC/Ferritin, TSH, free and total testosterone, 17‐OH progesterone, VDRL,FSH, LH, DHEA‐S, ANA, ESR, prolactin, Vitamin D

Anetoderma CBC, ANA, anti‐dsDNA, anti‐SSA/B, TSH, RPR, Lyme titer, HIV, fasting AM cortisol, C3/C4/CH50, protein C/S, anti‐thrombin III, anti‐cardiolipin abs, lupus anticoagulant, B2‐glycoprotein

Angioedema CBC, C1 est inhib, C1,C2,C4

Hereditary: C1‐nl; C2,C4,C1 est inhib‐ ↓ (C1‐INH levels may be nl but nonfunctional)

Acquired: C1‐↓; C2,C4,C1 est inhib‐ ↓CTCL CBC with peripheral smear (Sezary Prep), AST/ALT,

LDH, CXR, HIV, HTLV‐1, CD4/8 flow cytometry (CD5, CD7, CD45RO, CD26: CTCL protocol)

Dermatitis herpetiformis anti TTG‐IgG, IgA > endomysial ab, anti‐Gliadin ab (IgG and IgA), total IgA, CBC, CMP, Vitamin D

Dermatomyositis Antisynthetase panel: (Anti‐Jo‐1 PL‐7, EJ, OJ PL‐12), anti‐Mi‐2, CK, aldolase, LDH, CRP, anti‐SRP PFTs, anti‐aminoacyl‐tRNA synthetases (interstitial lung disease (ILD) association), anti P‐155 (cancer association), anti‐CADM (ILD association), anti‐MDA5 (RA‐like associations)

Flushing 24‐hour urine 5‐HIAA and metanephrines, norepinephrine, VMA, prostaglandin D2, dopamine, tryptase, histamine, plasma VIP, UA, serotonin, calcitonin (if thyroid nodule)

Hypercoagulability and thrombogenic vasculopathy

ANA, protein C/S, lupus anticoagulant, anti‐phospholipid ab, β2 glycoprotein ab, anti‐cardiolipin, hepatitis B/C, SPEP/UPEP, Factor V Leiden, prothrombin gene mutation, homocysteine level, MTHFR gene mutation

Hyperhidrosis (diffuse/sudden) CBC, HbA1c, cortisol, TSH, GH, serotonin, urine 5‐HIAA, urine 24‐hour catecholamines

LCV ROS neg: CBC, CMP, UA, ANA, HBV/HCV, Skin Bx +/‐ DIF

ROS pos: add ANCA, Cryo, ASO, HBV, ESR, RF, Complement, age‐appropriate cancer screening

MCTD Anti‐U1RNP, anti‐Ku, ANA, RF, CRP

PCOS Total and free testosterone, DHEA‐S, LH/FSH, sex hormone‐binding globulin, β‐HCG

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PCT/ pseudoporphyria HCV, Fe, 24‐hour urine porphyrins (Uro:copro> 8:1), CBC, LFT, lead levels, quantitative plasma porphyrins, stool porphyrins

Photosensitivity ANA, ENA (SSa/b)

Pruritus CBC/CMP, LFTs, TSH, bilirubin, CXR, UA, hepatitis B/C, peripheral blood smear, Fe, β‐HCG, ESR, HIV

SPEP/UPEP, stool ova and parasite, age‐appropriate cancer screening

Purpura CBC w/ peripheral smear, CMP, TSH, ANA, PT/PTT, bleeding time, c‐ANCA, p‐ANCA, SPEP/UPEP, cryoglobulins, vitamin K level, d‐dimer

Pyoderma gangrenosum CBC/CMP, UA, peripheral smear, ANA, RF, SPEP/UPEP, ANCA, antiphospholipid ab, RF, colonoscopy, Hep B/C

Recurrent furunculosis/carbunculosis

Skin culture w/ gram stain, CMP, blood glucose, HIV, hepatitis B/C, CH50, peripheral smear, SPEP, IgG/IgM/IgE, nitroblue tetrazolium (if concern for CGD)

Sarcoidosis CBC, CMP, Ca+, Serum ACE level, 1,25 Vit D, PTH, Alk Phos, ESR, ANA, CXR, QuantiFERON Gold

Scleroderma/CREST syndrome Anti‐Scl‐70, ANA, anti‐Jo‐1, anti‐centromere, RNA, polymerase I/III, RF, esophageal motility, PFTs, BUN/creatinine

Sjogren’s syndrome ANA, anti‐Ro/La, CRP, RF, anti‐alpha‐fodrin ab

Syphilis RPR/VDRL – primary; FTA‐ABS – secondary

SLE CBC/CMP, ANA, anti‐smith, dsDNA, UA, BUN/creatinine, ESR, ENA panel, C3/C4/CH50

TEN Check for IgA deficiency if Tx = IVIG as GammaGard needed (IgA depleted):

IVIG 2–4 g/kg (total dose, divided over 2–5 d, see TEN protocol pg. 227

Urticaria CBC, IgE, anti‐FcεRI (CUI), sinus X‐ray, hepatitis B/C, TSH, anti‐TPO, anti‐thyroglobulin, H. pylori, cryoglobulins

In children often due to strep: Check ASO, Rapid Strep

Urticarial vasculitis ESR, C4/CH50, anti‐FcεRI (CUI), anti‐C1q, ASO, RF, ANA, UA, SPEP, Hep B/C, CRP, C3/C4/CH50

Vitiligo CBC, TSH/Free T4, anti‐thyroid peroxidase (TPO), fasting blood glucose, 25‐OH Vitamin D, B12/folic acid, anti‐parietal gastric cell antibody (APGC)

Source: Adapted from Comprehensive Laboratory Disease Workups. Graham PM, Wilchowski S and Fivenson D. Directions in Residency. Spring 2016, pp.1–4.

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Management of acne

Regardless of subtype, always consider hormonal abnormalities on initial evaluation or if recalcitrant to treatment

If recalcitrant

If recalcitrant

Consider

If recalcitrant

If elevated

If recalcitrant

If recalcitrant, repeat course andconsider hormonal workup

Thiboutot D. Acne: hormonal concepts and therapy.Clin Dermatol. 2004 22(5):419–28

In all cases, consider hormonal workup if acne in a female patient is abrupt and/or severe in onset or associated with hirsutism, irregular menses,or less frequently: androgenetic alopecia, acanthosis nigricans, cushingoid features, clitoromegaly, deepened voice, or increased libido

Papular/pustular Cystic/scarringMixed: comedonal andpapular/pustular

Comedonal

Topical preparations of:retinoids, salicylates,azelaic acid, benzoylperoxide, antibiotics

Oral antibiotics, topicals (percomedonal regimine), orhormonal therapy consisting oforal contraceptives +/–spironolactone

Isotretinoin +/– (hormonaltherapy consisting of oralcontraceptives +/–spironolactone)If these treatments arecontraindicated ALA-PDTand laser treatments maybe consideredCombine therapies above

Titrate topicals to maximum doseand use combination therapy

DHEA-S: for adrenal source of androgensTestosterone, free and total: for gonadal source of androgensLH/FSH ratio > 2: consistent with Polycystic ovarian syndrome (PCOS)Obtain all tests apart from time of ovulation, i.e. before or during menstrual cycle and >4 weeks after discontinuing oral contraceptives

Endocrine consultTopical retinoids (for acne prophylaxis, skin cancer prevention and to ameliorate photoaging

Universal general maintenancepost clinical resolution

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Alopecia Workup

Hair Duration % of hair Microscopic/hair pull

Anagen 2–6 yr 85–90 Sheaths attached to roots

Catagen 2–3 wk <1 Intermediate appearance (transitional)

Telogen 3 mo 10–15 Tiny bulbs without sheaths, “club” root

Exogen Active shedding of hair shaft

Kenogen Rest period after shedding telogen; empty follicle

A. Associations1. Medications? Telogen effluvium associated medications:

anticonvulsants, anticoagulants, chemotherapy, psychiatric medications, antigout, antibiotics, and beta‐blockers

2. Hormones (pregnancy, menstruation, and OCPs)?3. Hair care/products?4. Diet (iron or protein deficiency)?5. Systemic illness/stress?

B. Cicatricial or non‐cicatricial?1. Non‐cicatricial: Is hair breaking off or coming out at the roots? Is

hair loss focal or diffuse?

Breakage Coming out at roots

Hair shaft defects, trichorrhexis nodosa, hair care (products, traction, and friction), tinea capitis, trichotillomania, anagen arrest/chemotherapy

Telogen effluvium, alopecia areata, androgenetic, syphilis, loose anagen, OCPs

Focal loss Diffuse loss

Hair care (traction), tinea capitis, trichotillomania, alopecia areata, syphilis, hair shaft defects

Telogen effluvium, anagen effluvium, androgenetic alopecia, hair shaft defects

2. Cicatricial: Is biopsy predominately lymphocytic, neutrophic, or mixed?

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Classification of cicatricial alopecia

Lymphocytic Neutrophilic Mixed

• Lichen planopilaris/LPP (including classic, frontal fibrosing, Graham‐Little)

• Central centrifugal cicatricial alopecia (CCCA)

• Alopecia mucinosa

• Keratosis follicularis spinulosa decalvans

• Chronic cutaneous LE

• Pseudopelade (Brocq)

• Folliculitis decalvans

• Dissecting cellulitis/ folliculitis

• Folliculitis/acne keloidalis

• Folliculitis/acne necrotica

• Erosive pustular dermatosis

Source: Adapted from Olsen EA, et al. North American Hair Research Society Summary of Sponsored Workshop on Cicatricial Alopecia. J Am Acad Dermatol. 2003;48:103–110.

C. Associated hair fragility?

Structural hair abnormalities by hair fragility

Increased fragility No increased fragility

Trichorrhexis invaginata (bamboo)

Monilethrix

Trichorrhexis nodosa

Trichothiodystrophy

Pili torti

Loose anagen

Pili annulati

Uncombable hair (spun‐glass)

Woolly hair

Pili bifurcati

Pili multigemini

Acquired progressive kinking

Source: Adapted from Hordinsky MK. Alopecias. In: Bolognia JL, Jorizzo JL, Rapini RP. Dermatology Vol. 1, Mosby; London. 2003, p. 1042.

D. Pull test and hair mount1. Pull test – Telogen hairs in telogen effluvium, Anagen hairs in

loose anagen syndrome. Helpful in identifying active areas in cicatricial alopecia or alopecia areata.

2. Hair mount

Disorder Hair mount findings

Monilethrix Beaded, pearl necklace, knots

Trichorrhexis nodosa Fractures, paint brushes

Trichorrhexis invaginata Bamboo/golf tee hair

Trichothiodystrophy Trichoschisis, tiger‐tail on polarization

Loose anagen Anagen hairs with ruffled cuticles and curled ends and lacking root sheaths

Pili torti Flattened, 180° irregularly spaced twists

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Disorder Hair mount findings

Uncombable hair Pili canaliculi et trianguli, triangular in cross‐section

Pili annulati Abnormal dark bands on polarization, air bubbles in cortex

Elejalde Pigment inclusions

Griscelli Pigment clumping

Menkes Multiple – pili torti, trichorrhexis nodosa, trichoptilosis

E. Hair count – helpful in quantifying hair loss1. Daily hair count: collect all hairs before shampooing (Normal <100)2. 60‐second hair count: comb for 60 seconds (Normal 10–15 hairs)

F. Biopsy – helpful in persistent alopecia, may help determine if cicatricial alopecia1. 4 mm punch biopsy for horizontal sectioning

a. Hair count: Caucasians should have ~40 total hairs (20–35 terminal, 5–10 vellus) while African‐Americans should have fewer (18 terminal, 3 vellus)* – assess catagen vs. telogen at the isthmus level and terminal vs. vellus at the infundibular level

b. Look at terminal to vellus** hair ratio:Normal >4 (~7–10T: 1V)Androgenic <2–4T: 1V

c. Look for characteristic findings:Alopecia areata: lymphocytes around anagen bulbsTrichotillomania: pigment casts, trichomalacia, catagen hairs, dermal hemorrhageAndrogenetic alopecia: miniaturized follicles

G. Labs – TSH, CBC, iron, TIBC, ferritin; consider RPR, ANACheck hormones (testosterone, DHEAS, and prolactin) – if irregular menses, infertility, hirsutism, severe acne, galactorrhea, or virilizationConsider checking “nutrition labs” – Vitamin D, thiamine, zinc, total protein

Ethnic differences in hair

Hair shaft structure

Hair shaft cross‐section

Others

African‐American

Coiled, curved

Elliptical, flattened

Lowest water content, slower growth, fewer cuticular layers at minor axes (only 1–2 not 6–8), longer major axis, less dense, large follicles

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Hair shaft structure

Hair shaft cross‐section

Others

Asian Straight Circular Largest follicular diameter; fewer eyelashes with lower lift‐up/curl‐up angles and greater diameter

Caucasian In between In between, oval

More dermal elastic fibers anchoring hair

*Vellus hairs – true vellus hairs (small and lack melanin) and miniaturized terminal hairs – histologically identical.

Telogen effluvium – workup and treatment

1. History: Medical/surgical; Stressors (stress scale 1–10), drugs, pregnancy, diet, weight loss/gain, metabolic/nutritional deficiency, endocrine dysfunctiona. Drugs: majority of drugs implicated, important to determine change

in dose, and history of adverse reaction2. Etiology:

a. Normal hair cycle is asynchronous – each follicle is independentb. TE – altered follicular growth cycle shedding:

a) Telogen shed > 35% loss – commonb) Anagen shed > 80% loss – rare

c. Immediate release – seen in fever, drugs, and stressd. Delayed release – prolongation of anagen phase, then synchronized

telogen phase in postpartum female3. Labs: CBC, CMP, TSH, DHEAS, free and total Testosterone, Ferritin, Zinc,

Vitamin D, Vit A, ANA, microsomal AB4. Physical exam/Bx:

a. Look at scalp, eyebrow, eyelash, and body hairb. Hair pull test: pull 40–60 hairs at 3 areas, <6–10 pull is positivec. Look for nail changesd. Bx: >7–35% telogen hairs

5. Treatments:a. Treat seb derm (healthy skin, healthy hair) – ketoconazole shampoob. Treat deficiency: Biotin forte 3 with zinc, Vit D, iron supplementc. High DHEAs – use spironolactoned. Find and remove triggerse. Minoxidil 5% liquid or foam

Androgenic alopecia – workup and treatment

1. Autosomal dominant – 23–28% prevalence2. Androgen influence on hair follicle and sebaceous glands

a. Alopecia: scalp – change from terminal to vellus hair