Hair & Nails

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.

Antonella Tosti, MD, Bianca Maria Piraccini, MD, and Débora Cadore de Farias, MD

Melanonychia describes a brown or black pigmentation of the nail plate caused by the presence of melanin. In this article, we review possible causes of melanonychia and discuss the main problems of management of patients with this condition. The goal in the management of melanonychia is early diagnosis of melanoma of the nail matrix and bed. Melanoma of the nail bed is also known as subungual melanoma. We discuss clinical, dermoscopic features that may help the clinician in selecting lesions that should have excisional biopsy and evaluate different options for the excision. Addressing melanonychia is still a difficult task, and the correct management of pigmented bands in children is far from established. Dermoscopy is possibly a useful tool but the real benefit of this technique, screening lesions to determine which ones need to be removed, remains to be proven.

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

Antonella Tosti, MD, Bianca Maria Piraccini, MD, and Débora Cadore de Farias, MD

Melanonychia describes a brown or black pigmentation of the nail plate caused by the presence of melanin. In this article, we review possible causes of melanonychia and discuss the main problems of management of patients with this condition. The goal in the management of melanonychia is early diagnosis of melanoma of the nail matrix and bed. Melanoma of the nail bed is also known as subungual melanoma. We discuss clinical, dermoscopic features that may help the clinician in selecting lesions that should have excisional biopsy and evaluate different options for the excision. Addressing melanonychia is still a difficult task, and the correct management of pigmented bands in children is far from established. Dermoscopy is possibly a useful tool but the real benefit of this technique, screening lesions to determine which ones need to be removed, remains to be proven.

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

Antonella Tosti, MD, Bianca Maria Piraccini, MD, and Débora Cadore de Farias, MD

Melanonychia describes a brown or black pigmentation of the nail plate caused by the presence of melanin. In this article, we review possible causes of melanonychia and discuss the main problems of management of patients with this condition. The goal in the management of melanonychia is early diagnosis of melanoma of the nail matrix and bed. Melanoma of the nail bed is also known as subungual melanoma. We discuss clinical, dermoscopic features that may help the clinician in selecting lesions that should have excisional biopsy and evaluate different options for the excision. Addressing melanonychia is still a difficult task, and the correct management of pigmented bands in children is far from established. Dermoscopy is possibly a useful tool but the real benefit of this technique, screening lesions to determine which ones need to be removed, remains to be proven.

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

Philippe Abimelec, MD

Nail surgery is part of the dermatologist’s armamentarium but it is often an afterthought in teaching dermatologic surgery. We will offer some practical hints about instruments and supplies, evaluation of pigmented lesions to determine whether a biopsy is needed, local anesthesia, and surgical techniques that should make procedures of the nail unit more efficient, less painful, and less likely to result in complications.

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

Philippe Abimelec, MD

Nail surgery is part of the dermatologist’s armamentarium but it is often an afterthought in teaching dermatologic surgery. We will offer some practical hints about instruments and supplies, evaluation of pigmented lesions to determine whether a biopsy is needed, local anesthesia, and surgical techniques that should make procedures of the nail unit more efficient, less painful, and less likely to result in complications.

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

Philippe Abimelec, MD

Nail surgery is part of the dermatologist’s armamentarium but it is often an afterthought in teaching dermatologic surgery. We will offer some practical hints about instruments and supplies, evaluation of pigmented lesions to determine whether a biopsy is needed, local anesthesia, and surgical techniques that should make procedures of the nail unit more efficient, less painful, and less likely to result in complications.

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

SAN ANTONIO — Having breast cancer patients don a pair of flexible frozen gloves during infusion of docetaxel markedly reduced the chemotherapy-induced fingernail toxicity known as onycholysis in a phase II multicenter Japanese trial.

This nail finding confirms an earlier French report, but the Japanese team was unable to confirm another French finding that these same frozen gloves also prevent docetaxel (Taxotere)-induced skin toxicity (J. Clin. Oncol. 2005;23:4424–9), Dr. Takahiro Nakayama said at the San Antonio Breast Cancer Symposium.

The Elasto-Gel frozen gloves, which look like cobalt-blue bulbous mittens or boxing gloves, contain a glycerin-based gel that remains soft at low temperatures. The reusable gloves, made by Southwest Technologies Inc., of Kansas City, Mo., are charged up by being placed in a subzero freezer for several hours. They contain an inner disposable liner that prevents direct skin contact with the icy material.

Recently a group at Georges Pomidou European Hospital in Paris reported in a phase II case-control study that an Elasto-Gel frozen sock significantly reduced docetaxel-induced toenail onycholysis but not cutaneous toxicity (Cancer 2008;112:1625–31).

Dr. Nakayama, a breast surgeon at Osaka University, Japan, reported on a comparative trial involving 70 breast cancer patients who used the frozen gloves and 52 others who were not offered them. The gloves are worn for 90 minutes, beginning 15 minutes prior to a 60-minute infusion of docetaxel. Because the gloves tended to warm up beyond the critical 0-degree Celsius threshold too quickly, investigators had subjects swap them for a fresh pair midway through the treatment session.

The mechanism of benefit is thought to involve reduced blood flow to the nail, Dr. Nakayama said in an interview.

No onycholysis occurred in 41% of the gloved group compared with 8% of controls. Rates of grades 1–3 fingernail damage as defined in National Cancer Institute Common Toxicity Criteria were significantly lower in the gloved patients.

However, rates of skin toxicity—rash, peeling, induration, fibrosis, hyperpigmentation, or hand-foot syndrome—did not differ significantly between the two groups. One-third of the gloved patients had no skin changes, as did 44% of controls. Half of the gloved group experienced grade 1 skin toxicity, compared with 42% of controls. Grade 2 toxicity occurred in 17% of gloved patients, while grade 2/3 toxicity was noted in 14% of controls.

Dr. Nakayama said he and his coinvestigators have concluded that the frozen gloves, with their lack of side effects, are a useful advance in supportive care and merit inclusion in routine clinical practice. “We use this in the clinic now on a daily basis,” the surgeon added.

He contends, however, that the design can be improved upon, and has partnered with a Japanese manufacturer in developing a more efficient glove. They also plan to develop a frozen sock.

The frozen glove study was partially supported by Sanofi-Aventis.

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO — Having breast cancer patients don a pair of flexible frozen gloves during infusion of docetaxel markedly reduced the chemotherapy-induced fingernail toxicity known as onycholysis in a phase II multicenter Japanese trial.

This nail finding confirms an earlier French report, but the Japanese team was unable to confirm another French finding that these same frozen gloves also prevent docetaxel (Taxotere)-induced skin toxicity (J. Clin. Oncol. 2005;23:4424–9), Dr. Takahiro Nakayama said at the San Antonio Breast Cancer Symposium.

The Elasto-Gel frozen gloves, which look like cobalt-blue bulbous mittens or boxing gloves, contain a glycerin-based gel that remains soft at low temperatures. The reusable gloves, made by Southwest Technologies Inc., of Kansas City, Mo., are charged up by being placed in a subzero freezer for several hours. They contain an inner disposable liner that prevents direct skin contact with the icy material.

Recently a group at Georges Pomidou European Hospital in Paris reported in a phase II case-control study that an Elasto-Gel frozen sock significantly reduced docetaxel-induced toenail onycholysis but not cutaneous toxicity (Cancer 2008;112:1625–31).

Dr. Nakayama, a breast surgeon at Osaka University, Japan, reported on a comparative trial involving 70 breast cancer patients who used the frozen gloves and 52 others who were not offered them. The gloves are worn for 90 minutes, beginning 15 minutes prior to a 60-minute infusion of docetaxel. Because the gloves tended to warm up beyond the critical 0-degree Celsius threshold too quickly, investigators had subjects swap them for a fresh pair midway through the treatment session.

The mechanism of benefit is thought to involve reduced blood flow to the nail, Dr. Nakayama said in an interview.

No onycholysis occurred in 41% of the gloved group compared with 8% of controls. Rates of grades 1–3 fingernail damage as defined in National Cancer Institute Common Toxicity Criteria were significantly lower in the gloved patients.

However, rates of skin toxicity—rash, peeling, induration, fibrosis, hyperpigmentation, or hand-foot syndrome—did not differ significantly between the two groups. One-third of the gloved patients had no skin changes, as did 44% of controls. Half of the gloved group experienced grade 1 skin toxicity, compared with 42% of controls. Grade 2 toxicity occurred in 17% of gloved patients, while grade 2/3 toxicity was noted in 14% of controls.

Dr. Nakayama said he and his coinvestigators have concluded that the frozen gloves, with their lack of side effects, are a useful advance in supportive care and merit inclusion in routine clinical practice. “We use this in the clinic now on a daily basis,” the surgeon added.

He contends, however, that the design can be improved upon, and has partnered with a Japanese manufacturer in developing a more efficient glove. They also plan to develop a frozen sock.

The frozen glove study was partially supported by Sanofi-Aventis.

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO — Having breast cancer patients don a pair of flexible frozen gloves during infusion of docetaxel markedly reduced the chemotherapy-induced fingernail toxicity known as onycholysis in a phase II multicenter Japanese trial.

This nail finding confirms an earlier French report, but the Japanese team was unable to confirm another French finding that these same frozen gloves also prevent docetaxel (Taxotere)-induced skin toxicity (J. Clin. Oncol. 2005;23:4424–9), Dr. Takahiro Nakayama said at the San Antonio Breast Cancer Symposium.

The Elasto-Gel frozen gloves, which look like cobalt-blue bulbous mittens or boxing gloves, contain a glycerin-based gel that remains soft at low temperatures. The reusable gloves, made by Southwest Technologies Inc., of Kansas City, Mo., are charged up by being placed in a subzero freezer for several hours. They contain an inner disposable liner that prevents direct skin contact with the icy material.

Recently a group at Georges Pomidou European Hospital in Paris reported in a phase II case-control study that an Elasto-Gel frozen sock significantly reduced docetaxel-induced toenail onycholysis but not cutaneous toxicity (Cancer 2008;112:1625–31).

Dr. Nakayama, a breast surgeon at Osaka University, Japan, reported on a comparative trial involving 70 breast cancer patients who used the frozen gloves and 52 others who were not offered them. The gloves are worn for 90 minutes, beginning 15 minutes prior to a 60-minute infusion of docetaxel. Because the gloves tended to warm up beyond the critical 0-degree Celsius threshold too quickly, investigators had subjects swap them for a fresh pair midway through the treatment session.

The mechanism of benefit is thought to involve reduced blood flow to the nail, Dr. Nakayama said in an interview.

No onycholysis occurred in 41% of the gloved group compared with 8% of controls. Rates of grades 1–3 fingernail damage as defined in National Cancer Institute Common Toxicity Criteria were significantly lower in the gloved patients.

However, rates of skin toxicity—rash, peeling, induration, fibrosis, hyperpigmentation, or hand-foot syndrome—did not differ significantly between the two groups. One-third of the gloved patients had no skin changes, as did 44% of controls. Half of the gloved group experienced grade 1 skin toxicity, compared with 42% of controls. Grade 2 toxicity occurred in 17% of gloved patients, while grade 2/3 toxicity was noted in 14% of controls.

Dr. Nakayama said he and his coinvestigators have concluded that the frozen gloves, with their lack of side effects, are a useful advance in supportive care and merit inclusion in routine clinical practice. “We use this in the clinic now on a daily basis,” the surgeon added.

He contends, however, that the design can be improved upon, and has partnered with a Japanese manufacturer in developing a more efficient glove. They also plan to develop a frozen sock.

The frozen glove study was partially supported by Sanofi-Aventis.

ELSEVIER GLOBAL MEDICAL NEWS