Hair and Nail Disorders

Hair and Nail Disorders Indian Medical PG Question 1: Finasteride is classified as a:

• A. 5-alpha reductase inhibitor (Correct Answer)
• B. Phosphodiesterase inhibitor
• C. Alpha-1 blocker
• D. Androgen receptor antagonist

Hair and Nail Disorders Explanation: ### ***5-alpha reductase inhibitor*** - **Finasteride** specifically inhibits the enzyme **5-alpha reductase**, preventing the conversion of **testosterone** to **dihydrotestosterone (DHT)** [2], [4]. - This reduction in DHT is clinically useful for treating conditions like **benign prostatic hyperplasia (BPH)** and **androgenetic alopecia** [4]. ### *Phosphodiesterase inhibitor* - **Phosphodiesterase inhibitors** (e.g., sildenafil) typically work by increasing levels of **cyclic GMP**, leading to **vasodilation** and are used for **erectile dysfunction** [3]. - Their mechanism of action is distinct from finasteride's effect on **hormone metabolism**. ### *Alpha-1 blocker* - **Alpha-1 blockers** (e.g., tamsulosin) primarily relax **smooth muscle** in the prostate and bladder neck, improving **urine flow** in BPH [3], [5]. - They act on **adrenergic receptors** and do not affect **hormone synthesis** or **metabolism** [3]. ### *Androgen receptor antagonist* - **Androgen receptor antagonists** (e.g., flutamide) directly block the binding of **androgens** (like testosterone and DHT) to their receptors [1], [4]. - While they also affect androgen action, their mechanism is different from finasteride's **enzyme inhibition** [4].

Hair and Nail Disorders Indian Medical PG Question 2: A patient presents with compulsive hair pulling resulting in irregular patchy hair loss. What is the most likely diagnosis?

• A. Trichotillomania (Correct Answer)
• B. Alopecia areata
• C. Telogen effluvium
• D. Tinea infection

Hair and Nail Disorders Explanation: ***Trichotillomania*** - This condition is characterized by **recurrent, irresistible urges to pull out hair**, typically resulting in **noticeable hair loss**. - The resulting patchy hair loss is often **irregular** and can occur in various areas, aligning with the patient's presentation. *Alopecia areata* - This is an **autoimmune condition** that causes smooth, **well-demarcated patches of hair loss**, not typically associated with compulsive pulling. - It usually presents with a sudden onset of hair loss without any preceding trauma or manipulation. *Telogen effluvium* - This condition involves **widespread hair thinning** due to a disturbance in the hair growth cycle, often triggered by stress or illness. - It does not involve compulsive hair pulling and typically results in increased hair shedding rather than patchy hair loss. *Tinea infection* - Also known as **ringworm**, this is a fungal infection that can cause **scaly, itchy patches of hair loss**, sometimes with inflammation and broken hairs. - While it can cause patchy hair loss, it is characterized by dermatological signs of infection (e.g., scaling, erythema) and not compulsive hair pulling.

Hair and Nail Disorders Indian Medical PG Question 3: A male presents with alopecia and exclamation mark hairs. Diagnosis?

• A. Alopecia areata (Correct Answer)
• B. Tinea capitis
• C. Telogen effluvium
• D. Androgenic alopecia

Hair and Nail Disorders Explanation: ***Alopecia areata*** - **Alopecia areata** is characterized by sudden, non-scarring hair loss that can affect any hair-bearing area, including the scalp. - The presence of **exclamation mark hairs** (hairs that are narrower closer to the scalp) is a classic dermatoscopic finding in alopecia areata and is highly suggestive of the diagnosis. *Tinea capitis* - **Tinea capitis** is a fungal infection of the scalp often presenting with scaling, erythema, and broken hairs, but typically not "exclamation mark hairs." - It may cause **patchy alopecia** but is usually associated with inflammation and sometimes pustules. *Telogen effluvium* - **Telogen effluvium** is a diffuse, non-scarring hair shedding that occurs after a stressful event, leading to widespread thinning rather than localized patches. - It primarily involves an increase in the number of hairs in the **telogen (resting) phase** and does not typically feature exclamation mark hairs. *Androgenic alopecia* - **Androgenic alopecia**, or male/female pattern baldness, is characterized by a gradual, patterned hair loss due to genetic and hormonal factors. - It involves the miniaturization of hair follicles and progressive thinning, but it does not present with **exclamation mark hairs** or discrete patches of complete hair loss.

Hair and Nail Disorders Indian Medical PG Question 4: HAIR-AN syndrome consists of which of the following?

• A. Acanthosis nigricans
• B. Insulin resistance
• C. Hyperandrogenism
• D. All of the options (Correct Answer)

Hair and Nail Disorders Explanation: ***All of the options*** - HAIR-AN syndrome is an acronym representing the combination of **HyperAndrogenism**, **Insulin Resistance**, and **Acanthosis Nigricans**. - This syndrome is often associated with **severe hyperinsulinemia** and is considered a severe form of polycystic ovarian syndrome (PCOS) [1]. *Acanthosis nigricans* - While **acanthosis nigricans** is a key component of HAIR-AN syndrome, it does not, by itself, define the entire syndrome. - This condition is characterized by **darkening and thickening of the skin**, particularly in body folds, and is a marker of insulin resistance. *Insulin resistance* - **Insulin resistance** is central to HAIR-AN syndrome, driving many of its metabolic and dermatological manifestations. - However, the definition of HAIR-AN syndrome requires the presence of hyperandrogenism and acanthosis nigricans in addition to insulin resistance to be complete. *Hyperandrogenism* - **Hyperandrogenism**, characterized by elevated androgen levels leading to symptoms like hirsutism and acne, is a critical feature of HAIR-AN syndrome [1]. - Similar to the other components, hyperandrogenism alone does not constitute the full syndrome, which necessitates the presence of insulin resistance and acanthosis nigricans.

Hair and Nail Disorders Indian Medical PG Question 5: Tics, hair pulling, and nail biting behaviors are best treated with?

• A. Behavior therapy (Correct Answer)
• B. Psychodynamic therapy
• C. ECT
• D. Medications

Hair and Nail Disorders Explanation: ***Behavior therapy*** - **Behavior therapy**, particularly **Habit Reversal Training (HRT)**, is the first-line and most effective treatment for tics, hair pulling (trichotillomania), and nail biting (onychophagia). - It involves teaching individuals to identify triggers and recognize urges, and then substituting the undesirable behavior with a competing response. *Psychodynamic therapy* - This therapy focuses on uncovering **unconscious conflicts** and past experiences that may contribute to symptoms. - While it can be helpful for some psychological issues, it is generally **less effective** for directly addressing specific behavioral symptoms like tics or body-focused repetitive behaviors. *ECT* - **Electroconvulsive therapy (ECT)** is a powerful somatic treatment primarily used for severe mental illnesses like **treatment-resistant depression** or catatonia. - It is **not indicated** for tics, hair pulling, or nail biting due to the high risks and lack of evidence for its efficacy in these conditions. *Medications* - While some medications (e.g., **antipsychotics** for severe tics, **SSRIs** for co-occurring anxiety/OCD) can be used as an adjunct, **behavioral therapy** is generally more effective and the first-line approach for these specific behaviors. - Medications alone rarely resolve these behaviors completely without behavioral intervention, and they often come with side effects.

Hair and Nail Disorders Indian Medical PG Question 6: Which of the following statements is incorrect regarding nail changes in various conditions?

• A. Onycholysis is seen in Psoriasis.
• B. Mees lines are indicative of Arsenic poisoning.
• C. Pterygium of nails is associated with Lichen Planus.
• D. Koilonychia is associated with Vitamin B12 deficiency. (Correct Answer)

Hair and Nail Disorders Explanation: ***Koilonychia is associated with Vitamin B12 deficiency.*** - **Koilonychia**, or "spoon nails," is primarily associated with **iron deficiency anemia**, not Vitamin B12 deficiency. - In Koilonychia, the nails become **thin, brittle**, and concave in shape. *Onycholysis is seen in Psoriasis.* - **Onycholysis** refers to the separation of the nail plate from the nail bed, which is a common nail finding in **psoriasis**. - Other nail changes in psoriasis include **pitting**, oil spots, and subungual hyperkeratosis. *Mees lines are indicative of Arsenic poisoning.* - **Mees lines** are transverse white lines or bands that appear across the nail plate, characteristic of severe illness or poisoning. - They are classically associated with **arsenic poisoning**, but can also be seen in other conditions like thallium poisoning or kidney failure. *Pterygium of nails is associated with Lichen Planus.* - **Pterygium unguis** involves the forward growth of the proximal nail fold (cuticle) onto the nail plate, leading to fusion. - It is a prominent and often distinguishing feature of **lichen planus** affecting the nails, which can lead to permanent nail deformity or loss.

Hair and Nail Disorders Indian Medical PG Question 7: The following patient presented to the OPD with history of hair loss. There was no erythema, scarring or scratching. Diagnosis is:

• A. Trichotillomania
• B. Alopecia areata (Correct Answer)
• C. Telogen effluvium
• D. Tinea infection

Hair and Nail Disorders Explanation: ***Alopecia areata*** - The image shows **well-demarcated patches of hair loss** with no signs of inflammation or scarring, which is characteristic of alopecia areata. - This condition is an **autoimmune disorder** where the immune system attacks hair follicles, leading to patchy hair loss. - Classic presentation includes **smooth, round patches** with no erythema or scarring. *Trichotillomania* - This condition involves **compulsive hair pulling**, which typically results in **irregularly shaped patches of hair loss** with hairs of varying lengths. - Hair loss in trichotillomania often shows **broken hair shafts** and may be associated with signs of trauma or follicular damage. - The absence of scratching/pulling behavior and the well-defined patches make this less likely. *Telogen effluvium* - Telogen effluvium presents as **diffuse hair shedding** (increased shedding of resting phase hairs) rather than the distinct, localized patches seen in the image. - It usually follows a **stressful event** (e.g., illness, surgery, childbirth) and there's no visible inflammation or scarring. - Would not present as well-demarcated patches. *Tinea infection* - Tinea capitis (ringworm of the scalp) would typically present with **erythema, scaling, inflammation**, and sometimes pustules or kerion formation within the patches of hair loss. - The patches of hair loss in tinea infections often show **broken hairs** or "black dots" where hairs have broken off at the scalp surface. - The **absence of erythema** in this case rules out tinea infection.

Hair and Nail Disorders Indian Medical PG Question 8: A male patient presents with patchy loss of hair involving the scalp, eyebrows, and beard with presence of grey hair in the affected areas. What is the most likely diagnosis?

• A. Androgenic alopecia
• B. Anagen effluvium
• C. Alopecia areata (Correct Answer)
• D. Telogen effluvium

Hair and Nail Disorders Explanation: ***Alopecia areata*** - This condition is characterized by **patchy hair loss** that can affect the scalp, eyebrows, and beard, and is often associated with the presence of **grey hairs** in the affected areas. - It is an **autoimmune disorder** where the immune system mistakenly attacks **hair follicles**, leading to non-scarring hair loss. *Androgenic alopecia* - This is commonly known as **male-pattern baldness** and typically presents as a receding hairline and thinning at the crown. - It is primarily driven by **genetics** and **androgen hormones**, and does not usually involve patchy loss or affect eyebrows and beard in the same way. *Anagen effluvium* - This condition is often caused by **chemotherapy** or other strong chemical exposures, leading to an abrupt and widespread loss of hair during the **anagen (growth) phase**. - Hair loss is typically diffuse and rapid, not usually localized to patches or accompanied by grey hair in specific areas. *Telogen effluvium* - This is a common form of **temporary hair loss** that occurs following a stressful event, fever, childbirth, or severe illness, causing premature shedding of hairs in the **telogen (resting) phase**. - It results in diffuse thinning rather than discrete patchy hair loss and is not typically associated with grey hair in the manner described.

Hair and Nail Disorders Indian Medical PG Question 9: A 70 year old farmer, presented to you with complaints of yellowish discolouration of his finger nails for the past 6 months, he also gives history of recurrent episodes of itching in the groin for which he used to take local home made herbal remedy. On examination 3 of his toe nails also show similar change with tunneling. Which among the following is the best test for rapid confirmation of your diagnosis?

• A. Tzanck smear
• B. KOH mount (Correct Answer)
• C. Woods lamp
• D. Biopsy

Hair and Nail Disorders Explanation: ***KOH mount*** - A **KOH mount** (potassium hydroxide) dissolves keratinocytes, allowing for direct visualization of fungal elements such as **hyphae** and **spores** under a microscope. This is the **most rapid and cost-effective test** for confirming fungal infections like **onychomycosis**. - The patient's presentation with **yellowish discoloration** and **"tunneling"** of nails (suggesting onycholysis and subungual hyperkeratosis), along with a history of recurrent groin itching (potentially **tinea cruris**), strongly points to a fungal infection. *Tzanck smear* - A **Tzanck smear** is primarily used to detect multinucleated giant cells in **herpesvirus infections** (e.g., herpes simplex, varicella-zoster). - It is not useful for identifying fungal elements responsible for nail discoloration or suspected onychomycosis. *Woods lamp* - A **Woods lamp** uses ultraviolet light to detect specific fluorescent substances, particularly useful for diagnosing certain **bacterial infections** (e.g., *Corynebacterium minutissimum* in erythrasma) or some **tinea capitis** species (*Microsporum*). - Most common dermatophytes causing onychomycosis **do not fluoresce** under a Wood's lamp, making it an unreliable diagnostic tool in this scenario. *Biopsy* - A **nail biopsy** (with histology and special stains like PAS) is a highly accurate diagnostic method for onychomycosis, especially when other tests are inconclusive. - However, it is an **invasive procedure**, takes more time for results, and is generally not the **most rapid** initial test compared to a KOH mount.

Hair and Nail Disorders Indian Medical PG Question 10: In a patient with the following lesion on scalp, what changes are seen in the nails?

• A. Azure nails
• B. Dorsal pterygium of nails
• C. Pitting of nails (Correct Answer)
• D. Yellow nail discolouration

Hair and Nail Disorders Explanation: ***Pitting of nails*** - The image shows a patch of **alopecia areata** on the scalp. **Nail pitting** is the most common and characteristic nail change associated with alopecia areata, occurring in **10-66% of cases**. - Pitting appears as small depressions or **"ice-pick" marks** on the nail surface, resulting from defective nail matrix keratinization. - Other nail changes in alopecia areata include **trachyonychia (rough nails), red spotted lunulae, onycholysis**, and **Beau's lines**. *Dorsal pterygium of nails* - **Dorsal pterygium** occurs when the proximal nail fold fuses with and extends over the nail plate, creating a wing-like scar. - This is classically associated with **lichen planus, trauma, burns, vasculitis**, and **graft-versus-host disease** — **NOT alopecia areata**. - It can lead to permanent nail dystrophy or nail loss. *Azure nails* - **Azure nails** (blue nails) are typically associated with **Wilson's disease** (copper accumulation) or **minocycline use**, not alopecia areata. - They represent a blue-gray discoloration of the nail bed or lunula. *Yellow nail discolouration* - **Yellow nail syndrome** is a rare condition characterized by slow-growing, thickened, yellow nails, often associated with **lymphedema** and **respiratory problems** (pleural effusions, chronic bronchitis). - It is not linked to alopecia areata.

Hair and Nail Disorders Flashcard 1 of 10

Question: _____ hair are often seen at the margins of the bald patches during active phases of alopecia areata

Answer: Exclamation mark

Hair and Nail Disorders Flashcard 2 of 10

Question: Causes for non-scarring alopecia: THATS STDT_____ (Non Inflammatory Type  - grey patch and black dot types)Hormonal - Hypothyroidism, Androgenetic alopeciaAnagen effluvium, Alopecia areataTrichotillomaniaSecondary syphilis (moth eaten alopecia)SLE(predominantly causes non-scarring alopecia but also can cause scarring alopecia)Telogen effluviumDeficiency of Zinc, Iron

Answer: inea capitis

Hair and Nail Disorders Flashcard 3 of 10

Question: Keratin filaments present in nails are _____

Answer: K6/K16

Hair and Nail Disorders Flashcard 4 of 10

Question: Alopecia areata involving the entire scalp is referred to as _____

Answer: alopecia totalis

Hair and Nail Disorders Flashcard 5 of 10

Question: _____ or 20 nail dystrophy, is seen in lichen planus

Answer: Trachonychia

Hair and Nail Disorders Flashcard 6 of 10

Question: What is the characteristic pattern of nail pitting seen in alopecia areata?_____

Answer: Fine-stippled pitting

Hair and Nail Disorders Flashcard 7 of 10

Question: Muehrcke's lines on nails are specific for _____ and is due to pathology in the nail bed

Answer: hypoalbuminemia

Hair and Nail Disorders Flashcard 8 of 10

Question: _____ sign is melanonychia with the pigmentation of proximal nail fold seen in subungual melanoma

Answer: Hutchinson's

Hair and Nail Disorders Flashcard 9 of 10

Question: Punctate leukonychia is caused by minor trauma to the nail _____ in manicures or also seen in alopecia areata

Answer: matrix

Hair and Nail Disorders Flashcard 10 of 10

Question: _____ is a neurocutaneous disorder associated with ungual fibromas, which are flesh-colored lumps emerging from nail folds

Answer: Tuberous sclerosis