Alopecia areata  

Alopecia is the loss of hair from any hair-bearing area of the body, but most often the scalp. It may be congenital or acquired, circumscribed or diffuse, and cicatricial or non-scarring. Androgenetic alopecia, a type of diffuse, non-scarring, acquired alopecia, is the most common, affecting > 70% of the general population by the age of 70. Alopecia areata, an acquired, circumscribed, non-scarring alopecia, is the next most common type. Clinical diagnosis is usually possible. In ambiguous cases, diagnosis is aided by microscopic examination of the hair, trichograms, and scalp biopsy. Treatment depends on the type of alopecia and includes long-term (at least one year) use of topical minoxidil, corticosteroids (topical, intralesional, or oral), or antiandrogens. Surgery (hair transplant) or camouflaging techniques are used when medical therapy fails. The prognosis is variable and depends on the etiology and severity of hair loss. 

• Definition: Hair loss in well demarcated patches due to immune mediated inflammation of hair follicles 
• Epidemiology  o Prevalence: 1 in 1000 people  o Age: mostly in people < 30 years  o Sex: ♂ = ♀  
• Etiology  
  • Immune mediated inflammation and disruption of anagen phase hair follicles → well defined patches of non-scarring hair loss  
  • A trigger factor (emotional stress, infections, pregnancy, etc.) may precede some cases  o Family history in up to 20% of cases  
• Clinical features  o Abrupt onset (within weeks) o Smooth, circular, well defined patches of hair loss without scarring (Bland scalp)  o Exclamation point hairs  o Various patterns of distribution  o Nail involvement (up to 40% of cases): nail pitting, onycholysis, Beau lines, etc.  
• Diagnostics: usually clinical, biopsy rarely necessary + histology, trichogram 
• Differential diagnosis  
  • Trichotillomania: Compulsive pulling out of one’s own hair → ill-defined patchy hair loss and hairs of different lengths.  
  • Tinea capitis: The affected areas of scalp are scaly compared to the smooth hair loss of alopecia o Secondary syphilis: patchy hair loss → moth-eaten appearance of scalp 
  • Brocq pseudopelade 
• Treatment  of Intralesional steroids (triamcinolone)  
  • Topical immunotherapy (DCP (diphenylcyclopropenone) or SADBE (squaric acid dibutyl ester) o PUVA treatment (Psoralen + UVA) 
• Prognosis: Is poor for alopecia universalis and totalis  

B38) Androgenic alopecia. 

Androgenic alopecia (Male pattern hair loss) 

Hair loss that is caused by the effect of dihydrotestosterone on the the hair follicle. Patients present with a receding hairline and a thinning crown. Androgenic alopecia may be caused by increased sensitivity of dihydrotestosterone receptors in the hair follicle to testosterone (hereditary / idiopathic), or by conditions that result in hyperandrogenism (e.g., polycystic ovarian disease, anabolic steroid use). 

Medication 

Hair loss can be slowed or reversed in its early stages with medication. Medications approved by the United States’ Food and Drug Administration (FDA) to treat male-pattern hair loss include minoxidil and finasteride. 

Androgen-dependent 

Finasteride is a medication of the 5α-reductase inhibitors (5-ARIs) class. By inhibiting type II 5-ARI, finasteride prevents the conversion of testosterone to dihydrotestosterone in various tissues including the scalp. Increased hair on the scalp can be seen within three months of starting finasteride treatment and longer-term studies have demonstrated increased hair on the scalp at 24 and 48 months with continued use. Treatment with finasteride more effectively treats male-pattern hair loss at the vertex than male-pattern hair loss at the front of the head and temples. 

Dutasteride is a medication in the same class as finasteride but inhibits both type I and type II 5-alpha reductase. Dutasteride is approved for the treatment of male-pattern hair loss in Korea and Japan, but not in the United States. However, it is commonly used off-label to treat male-pattern hair loss. Androgen-independent 

Minoxidil is a growth stimulant that stimulates already-damaged hair follicles to produce normal hair. Minoxidil does not, however, provide any protection to the follicles from further DHT damage. When a follicle is destroyed by DHT, minoxidil will no longer be able to have any more regrowth effects on that follicle.^{[citation needed]} Other treatments include tretinoin combined with minoxidil, ketoconazole shampoo, spironolactone, alfatradiol, and topilutamide (fluridil). 

Procedures 

More advanced cases may be resistant or unresponsive to medical therapy and require hair transplantation. Naturally occurring units of one to four hairs, called follicular units, are excised and moved to areas of hair restoration. These follicular units are surgically implanted in the scalp in close proximity and in large numbers. The grafts are obtained from either follicular unit transplantation (FUT) or follicular unit extraction (FUE). In the former, a strip of skin with follicular units is extracted and dissected into individual follicular unit grafts. The surgeon then implants the grafts into small incisions, called recipient sites.^[25][26] Specialized scalp tattoos can also mimic the appearance of a short, buzzed haircut. Alternative therapies 

Many people use unproven treatments. There is no evidence for vitamins, minerals, or other dietary supplements. As of 2008, there is little evidence to support the use of lasers to treat male-pattern hair loss. The same applies to special lights.Dietary supplements are not typically recommended.A 2015 review found a growing number of papers in which plant extracts were studied but only one randomized controlled clinical trial, namely a study in 10 people of saw palmetto extract. 

B39) Diseases of the nails. 

Diseases 

Anatomy of the basic parts of a human nail. A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. eponychium; H. free margin. 

• Onychia is an inflammation of the nail folds (surrounding tissue of the nail plate) of the nail with formation of pus and shedding of the nail. Onychia results from the introduction of microscopic pathogens through small wounds. 
• Onychocryptosis, commonly known as “ingrown nails” (unguis incarnatus), can affect either the fingers or the toes. In this condition, the nail cuts into one or both sides of the nail bed, resulting in inflammation and possibly infection. The relative rarity of this condition in the fingers suggests that pressure from the ground or shoe against the toe is a prime factor. The movements involved in walking or other physical disturbances can contribute to the problem. Mild onychocryptosis, particularly in the absence of infection, can be treated by trimming and rounding the nail. More advanced cases, which usually include infection, are treated by surgically excising the ingrowing portion of the nail down to its bony origin and thermally or chemically cauterizing the matrix, or ‘root’, to prevent recurrence. This surgery is called matrixectomy. The best results are achieved by cauterizing the matrix with phenol. The Vandenbos Procedure is a highly effective method that focuses on excision of excessive nail fold tissue without affecting the healthy nail and nail matrix. The Vandenbos procedure is showing high success rates in eliminating Onychocryptosis without altering the normal nail. Another, much less effective, treatment is excision of the matrix, sometimes called a ‘cold steel procedure’. 
• Onychodystrophy is a deformation of the nails that can result from cancer chemotherapy which includes bleomycin, hydroxyurea, or 5-fluorouracil. It can include discoloration of the nail, or dyschromia. 
• Onychogryposis, also called “ram’s-horn nail”, is a thickening and increase in curvature of the nail. It is usually the result of injury to the matrix. It may be partially hereditary and can also occur as a result of long-term neglect. It is most commonly seen in the great toe but may be seen in other toes as well as the fingernails. An affected nail has many grooves and ridges, is brownish in color, and grows more quickly on one side than on the other. The thick curved nail is difficult to cut, and often remains untrimmed, exacerbating the problem. 

Onychomycosis in every nail of the right foot. 

• Onycholysis is a loosening of the exposed portion of the nail from the nail bed, usually beginning at the free edge and continuing to the lunula. It is frequently associated with an internal disorder, trauma, infection, nail fungi, allergy to nail enhancement products, or side effects of drugs. 
• Onychomadesis is the separation and falling off of a nail from the nail bed. Common causes include localized infection, minor injury to the matrix bed, or severe systemic illness. It is sometimes a side effect of chemotherapy or x-ray treatments for cancer. A new nail plate will form once the cause of the disease is removed. 
• Onychomycosis, also known as tinea unguium, is a contagious infection of the nail caused by the same fungal organisms which cause ringworm of the skin (Trichophyton rubrum or T. mentagrophytes, rarely other trichophyton species or Epidermophyton floccosu). It can result in discoloration, thickening, chalkiness, or crumbling of the nails and is often treated by powerful oral medications which, rarely, can cause severe side effects including liver failure. Mild onychomycosis sometimes responds to a combination of topical antifungal medication, sometimes applied as special medicinal nail lacquer, and periodic filing of the nail surface. For advanced onychomycosis, especially if more than one nail is infected, systemic medication (pills) is preferred. Home remedies are often used, although their effectiveness is disputed. 

Subungual hematoma (mild) 

• Onychophosis is a growth of horny epithelium in the nail. 
• Onychoptosis is the periodic shedding of one or more nails, in whole or part. This condition may follow certain diseases such as syphilis, or can result from fever, trauma, systemic upsets or adverse reaction to drugs. 
• Onychorrhexis also known as brittle nails, is brittleness with breakage of fingernails or toenails. 
• Paronychia is a bacterial or fungal infection where the nail and skin meet. 
• Koilonychia is when the nail curves upwards (becomes spoon-shaped) due to an iron deficiency. The normal process of change is: brittle nails, straight nails, spoon-shaped nails. 
• Subungual hematoma occurs when trauma to the nail results in a collection of blood, or hematoma, under the nail. It may result from an acute injury or from repeated minor trauma such as running in undersized shoes. Acute subungual hematomas are quite painful, and are usually treated by releasing the blood by creating a small hole in the nail. Drilling and thermal cautery are common methods for creating the hole. Thermal cautery is not used on acrylic nails because they are flammable. 
• Onychomatricoma, a tumor of the nail matrix. 
• Nail Pemphigus, an auto-immune disease. 
• Erythronychia, red bands in the nail from some inflammatory conditions. 
• Melanonychia, a black or brown discoloration of the nail, with numerous causes. 

Abb. 3: Die vier Subtypen der Nagelmykose im Überblick  

Abb. 5: Nagelpsoriasis: Im Gegensatz zur Onychomykose zeigt sich bei der die Nägel befallenden Schuppenflechte mehrheitlich ein Befall aller Nägel.  

Abb. 6: Druck-bedingte Nagelschädigung: Traumatische Nagelschädigung mit Nageleinblutung aufgrund zu enger Skischuhe  

Abb. 7: Symmetrischer Befall: Druckbedingte Verdickung und Verfärbung beider Großzehennägel aufgrund orthopädischer Fehlstellung.  

B40) Seborrhoea. Acne. 

Seborrhea  

Abnormally increased production of sebum (an oily secretion) by the sebaceous glands of the face and/or scalp, resulting in oily skin with greasy scales. Seborrhea usually occurs in individuals with a 

genetic predisposition, in certain diseases such as Parkinson’s syndrome, and as a side effect of certain medications (e.g., methyl dopa, cimetidine). It can lead to seborrheic dermatitis and/or acne vulgaris.  

Acne vulgaris  

Abstract  

Acne vulgaris is a common skin disease that affects most individuals at some point in their lives. It is classified into different forms which vary in severity, lesion type, and localization, with the face commonly involved. The hallmark of acne are comedones, which can develop further into inflammatory papules, pustules, or even abscesses and nodules. Symptoms typically begin in early puberty and cease spontaneously during the third decade of life. The are multiple etiological factors: genetic predisposition, seborrhea, and hyperkeratosis are known to promote the development of acne. Topical and systemic treatment options are available to counteract inflammation and hyperkeratosis, as well as to help purify the skin.