Chapters Transcript Video Hair and Nail Disorders dr Renee Howard earned her medical degree at UCSF. She completed her pediatric residency at UCSF. Benioff Children's Hospital, Oakland right here with us and went on to serve as chief resident. She also completed a residency in dermatology at UCSF and served as their president. Dr Howard is a committed attending, who cares deeply about her patients and about resident education and shows her passion for teaching with every resident who is lucky enough to rotate through dermatology with her, which I got to witness myself as a second year. So without further ado I will pass it off to Dr Howard who is going to speak on hair and nail disorders today. Thanks so much. Thank you Shelagh. I thought this would be a good topic because it's something that you don't really learn in medical school and in pediatric residency unless you do a Durham rotation, it's just it comes up all the time clinically and um it's kind of a hard thing to learn about, mainly because in both the hair and the nails, there's only a few ways that all different kinds of diseases present, so it's really hard to know how to sort them out and how to approach them. So I'm hoping to help you with that today. Um So common problems that are heard to deal with the pigment and nail streak is one thing I'm gonna address that I'm actively managing a patient right now. So I thought it was interesting that this came up right before my talk and I'll talk about that a bit more later, so I don't have any conflicts of interest, I don't have any um financial investments in any hair and nail cup companies or supplements. So, I think the first thing that is the most common dilemma that comes up in pediatric practice is distinguishing a fungal nail infection or on psychosis from an inflammatory nail disease, like psoriasis. So, I hope after this, you'll you'll have that down pretty well and then managing pigmented streets can be really challenging and very um fair inducing for families, They get really um worried about these and it's really good to know how to manage them. And finally, hair loss is good thing to have a really nailed down approach. So we're gonna spend the most time on the hair loss. So, first on a comic, oh sis, this is an example of like psychosis in a teen, you can see that there's also a rash on the foot that looks really non specific, that rashes Tenia pedis and this toenail. Um this hyper characteristic and thick and broken down is on psychosis. So that is a dramatic dramatic fight, fungal infection of the nail with tenia pedis and adolescent. The most common scenario that you will see nail dystrophy and patients end of story. Um but here you see a toddler who has kind of a more subtle nail dystrophy. The nail surface is dull. There's a little bit of figuring at the end of the nail plate that's gonna cost yah, we have lots of fancy names to describe nails. Um, you can see a little bit of milder changes in this nail here and that is also on a psychosis. So on psychosis and fungal nail infection does span the pediatric spectrum from toddler up to adolescence. Most toddlers with fungal nail infections and with Tenia pedis have a family member with uh Tenia pedis or a nail infection, usually a parent. And it's not just the exposure in the household, but there's also a genetic susceptibility to fungal infections or to modify infections that kind of runs through life. So there's a nature and nurture component to it. It's much less common in kids than adults and that's because kids nails grow faster. Their nail plates are thinner so they're not as susceptible to nail infections as adults. But the incident seems to be increasing over time. About 15% of nail dystrophy in childhood is on the mucosa. So, um, the whole through 0-18, you can see that it's not the majority of patients. So that's why it's important to know how to pick those out. Um, it's, I think important to prove the diagnosis because the treatments are really hard to use and not FDA approved in Children, which is the oral treatment and we'll talk about that. The safety is not known. There are some small case series, but not FDA approved case control studies, etcetera and young kids and adults. There are, and I do use this oral treatment and teenagers. So here's another example of a young child with psychosis. And you can see again the thickening of the nail. And I want to point out the bleeding of the nail bed. So the nail bed is the skin that the nail plate or the carbonized hard structure is attached to. And when you have a nail infection that can pull off and rip off when you're running around with your shoes on and cause pain and limping. Um And so this is an example of when we would start thinking about treatment even in a young child balancing the risk benefit. So again young Children this toddler here, two year old since the nail plate, you can even see how kind of how thin the nail plate is. Um And the fact that they grow faster means that you can use a topical treatment and look for six months and you should see some significant clearing growing in from the base of the cuticle here. Um so I usually just start with turbine if in cream for any child, probably under 10. So under puberty it's worth a try. Okay, it may not work but there's no risk involved a little bit of a hassle and you can do it once a day at night to benefit in cream 1% covered by medical Medicaid. Um And in six months you'll start to see a normal nail growing from the proximal nail fold, which is this um the proximal part here where the nail is made this it'll grow out normal. So the distal end will still look a little funky. And do I do labs when I'm using oral treatment? I do because it's not FDA approved. So if a child is having pain and disability dysfunction from their nail infection and I'm going to use oral benefit then I will do a baseline cbc and A. S. T. A. L. T. So you can get battle toxicity and you get neutropenia And then I'll recheck that CBC in six weeks. And I have run into some incidental like cyclic neutropenia and stuff. So sometimes you end up having to manage the lab. Um but you can't get neutropenia from 15. It's not a dangerous neutropenia but it does mean you need to stop and then usually it's just a transient ischemia, not a serious hepatitis in kids. So that's why I'm comfortable using it. If you are a 45 year old patient and you come in to see me and you drink alcohol and you have a toenail infection, I will politely tell you that I won't treat you. I don't treat adults over the age of 21. I really don't feel comfortable using to benefit because there have been liver transplants from oral to benefit. News. And I just think it's better to paint your toenails because the oral to benefit in adults has a very low clearance rate and a very high recurrence rate. So to me it's not worth it. But for a young teen and I'm very frank with them about alcohol, like none, you can't have any um or a child ironically, even though it's not FDA approved, I think it's safer to use at younger ages. The the way I dose it in young kids since it's not FDA approved, the studies that have been done in kids, the dosing is six mg per kilogram, the max is 250 a day. So once you read that, which that weight, you just use the adult dose, I only use the tablets. It's really hard to get the Granules, it comes in a gradual dozing but i it's really hard to get it. And so I just have parents get a pill crusher and um I round up or down for a quarter tab half tab or a whole tab. So whatever they're closest to um and crush it up and put it in food once a day and grizzly filter needs to be given with fatty food. But even if, I mean you can give with any food. So um it's supposed to be non acidic. So basically putting ice cream is the best And I do. Usually I look at six weeks, I look and if it looks like it's really clearing, I don't go the whole 12 weeks with teenagers I do with over puberty I do, but with the younger kids, if it's looking really good at six weeks, you can stop and if you want to just make sure it doesn't come right back, you can have them use the topic culture benefit for another six weeks and take a look. So you can shorten the course. Um depending on how like that kid who had the bleeding, I would probably do a whole three months because she's got a really thick nail. But this child here, if I do have to use oral, I would look at the kid at six weeks and you may be surprised that most of it's grown out an adult, it takes an entire year to grow toenail. So you have to watch it for an entire year as it grows out. So again, it's really important to diagnose and the promise it's really hard to do that in the general Pete's office and if you work in a hospital you could conceivably um kind of rough this up a little bit, but I don't, you guys don't have curates, you could use a blade and then you could swab it with just a culture at and send it for fungal culture, a dramatic fight. Culture, the yield is going to be lower. Um because what you really need by, I use a Keret. So I get crumbles of the nail. You want to get this stuff that's under the nail plate that's thickened. So not the top of the nail, but under the nail here, you could get it on top of the nail because it's really super white and that crumbles right off and I have the gratified media right in my clinic so we just we played it right in clinic and sent up to the lab to be followed. Um So here's an example of a patient that I um I scraped her nail and plated it. Um It did grow trying to fight and species so try to find the species are the most common cause of Tina Peterson article My courses at all ages trying to find rubidium specifically. So it's different from the tiny capital stratified veterans. So the parent called me two weeks after starting treatment and complaining that the nails hadn't changed. And so I re explained to her that it's gonna taste take this as the kid. I said I would treat for three months it's going to take us the full 12 weeks of treatment even start to see the normal nail growing up. So this is the photo after two weeks the parents sent me and this is after three months you can see the nail here is normal and at the very base it still looks a little bit um dis trophic but you can see almost a dividing line here between the dis trophic nail and the proximal nail that's growing out fine. So this is a child that I put on some topic. Als after she finished the corals and kept watching her to make sure to lower the recurrence rate. The recurrence is a huge problem with oral treatment. Again. Remember there's a genetic susceptibility to recurrent gratified infections which is probably anchored in the immune response. I just tell people some people immune system sees dramatic and goes and if you think about it in terms of mortality, that's not an inappropriate response. It's not a dangerous infection. Um And then the teens I discussed the risk benefit, I make sure that they're not drinking any alcohol. I warned them against Tylenol as well which is I don't combine it with Accutane either, which is also a liver irritant. Um So the older the kid the lower the efficacy and the higher the recurrence rates. And then you're getting more like an 18 year old more into the adult numbers, which is about 17 17% clearance. And you've got about a 50 50 chance of recurrence. So you got about 8% chance of clearing this person's on psychosis forever. So you see why I'm so like kind of pessimistic about it in the bigger studies, of course the initial studies were so positive, which so of course this is the nature of things. Right? And as we got more data, the numbers kept going down in terms of its efficacy. I do monitor teams with labs but I do um at six and 12 weeks. I don't always do baseline labs unless there's some respect. Er And the dose is very easy, it's 250 a day for 12 weeks. So there are some new topical is coming down the pike in a console into the borough. So um the you might recognize this as chris and borough which is a new eczema appointment that's been around a few years now but the boron molecule helps the penetration of topic als and so this looks like it's going to be more effective than cyclic process which I don't use is super expensive and none of my Medicaid patients can get it. I just use lambda still topical or too many fine. Sorry? Um But it looks like these two agents might be more efficacious and they're gonna work their way towards pediatrics eventually. So just stay tuned for that. And the dosing regimens used in this study was once a day for two weeks, twice a week for three years. So again this issue of recurrence is pretty huge but I think it's a small price to pay to use topical twice a week. So now let's switch gears to nail psoriasis. So we see a lot of psoriasis in the dermatology clinic, it's hard to manage. So it tends to get referred that's appropriate. And nail psoriasis is especially hard to manage. About 17 to 40% of kids with psoriasis have affected nails. Um That is presents as very similar to an income psychosis as some seven hyper keratosis you get that thick crumbling nail dull surface discoloration. And here's an example of a child who has both fingernails and toenails. And here's another example of fingernails where the psoriasis is more destructive. So you just see complete destruction of the nail plate and you can imagine that's not just a cosmetic problem, that's a functional problem once you start having affected fingernails in terms of using your hands for things. Um And you still get that that pulling off phenomena where you get bleeding and pain and some bungle bleeding hematomas. You don't get hematomas because it comes out because it's lifted up. But it can be very disfiguring and um effect function. And likewise in the on the feet with athletics and stuff you can you can get some bungle hematomas and pain. So nails can be isolated findings but usually there's other findings uh signs of psoriasis. That's the first thing I tell people for diagnosis is to look at the whole body. Now here you see some hyper carry topic firm plaques on the soul. So that is psoriasis. That is not a callus, that is psoriasis. So you get hyper proliferation of the um of the skin and that skin just piles up. And here's another child who presented with fingernails and toenails. And then she proceeded to develop scalp psoriasis which was very itchy inverse psoriasis in her armpit. Um And we could not get these nails clear with topical topical steroid. And I actually started her methotrexate because her nails were crumbling. Um And then she developed the psoriasis. The methotrexate didn't work for her plaque type psoriasis which was getting more and more body surface area every time I saw her. So she's now on Kassian ticks which is a biologic, so not first line, super expensive, it's a shot. But we will treat nails and we do treat psoriasis and kids with targeted therapy. Um And that's something we do and you don't have to worry about doing because the drugs are really hard to get. You need like a person who's specialized in trying to get them for the patients. So just a comparison side to side in a table, which I love tables because I like to be able to compare and contrast. So psoriasis they both have, you see sublingual hyper character Asus discoloration. So remember how I said nail disease sort of all a lot of different things present in the same way. So the findings that separate them are going to be subtle. So one thing to know is you can look for pitt so pits are little tiny um defects in the nail plate. And if you sidelight the nail with your with a flashlight or your phone you can see the pinning a little bit. Um Eat more easily splinter hemorrhages or tiny little bleeds under the nails that nail plate separates from the nail bed ah nickel licenses lifting of the nail. Again the plate from the bed to get this white kind of mark or circle underneath. And psoriasis tends to affect both fingernails and toenails. Whereas on psychosis usually just affects the feet. If you see a child with ana call necrosis of the hands then I think about tiny capital because they're scratching their tiny capitals and they get in their fingernails that way. But it's rare to see foot fungus going to the fingernail. It happens but it's really rare. So there's another kind of psychosis that is very superficial. It's called white superficial and psychosis and they're bright, bright bright white. Um Mac tools on the nail. But then if you scratch them they get really flaky. So that's that's also a clue that it's psychosis and not psoriasis, you don't get that with psoriasis, other physical exams. So you want to do a full skin exam. You wanna for psoriasis look at the scalp, look behind the ears, look in the ears, look at the elbows and knees. Hands, palms and soles and then armpits and groin. Most common presentation of psoriasis is elbows and knees extend, sir with some scaling erythema and sometimes you just see some kind of really really dry and not very scaly if it's mild but that's still a clue that it's psoriasis with a nickel psychosis. You want to part those toes, especially the pinkie toe on the fourth toe, the interdigital space. You want to look in there for peeling and redness and um I treat with topical antifungal um And oral antifungal for a week. If I see tenia pedis because I really want that to um make sure we clear that up quickly. Um Both so we don't spread it to other people. So you don't have a portal of entry for bacteria. And so we make sure that's covered completely as we're getting rid of the toenail fungus and it doesn't come back from the feet. Um We rarely do skin biopsy on nails. It requires a special technique. I don't do it. It has to be somebody who knows how to do a nail biopsy. So I don't usually do for psoriasis a clinical diagnosis and ill treats presumptively if I'm sure it's psoriasis and not on a psychosis but I do these studies if I'm not sure. So I'm like I think this is psoriasis but just like with scaling on the scalp a lot of times like in our population we see martini capitals than um in our community. So I will do more demand if I cultures to rule it out. And then in terms of treatment um you guys can start with triumphs and alone, even little kids you can do transcend alone 0.1. Cream or ointment family preference. And the place you put it on is approximately will fold which is the cuticle, the base of the nail that's where the nail is made and that's where it's getting inflamed. So that's where we put um as dermatologists we used is also we use a class one steroid but you guys don't have to start with that because we see the more severe cases and as I mentioned with that case we do use oral methotrexate and biologics if it's severe. And of course that's us. You need to refer for that in terms of the we talked a little bit about this already. The topical you can use amazon if you want. I think the benefit is a little bit better because it's cycle instead of static on the fungus. But either one of these is fine and they're both covered by Medicaid even though they're over the counter. So that helps the families even though it's pretty cheap. And then we talked about the oral to benefit which is also very easily covered by insurance. I don't use grizzly fold in for toenails if I have any capital and fingernails I will use grizzly fold in. Um, but I use oral to benefit if I have a toenail. The grizzly folding just doesn't, it doesn't work for toenails toenail fungus. And we talked about the monitoring already. So unfortunately I wish it was as simple as that. But you can have on a psychosis and psoriasis and the same nail this kid just had tenure by the way. But they've done studies where they culture psoriatic nails and they know the person has psoriasis and they grow fungus and they treated with antifungal. it's a little better. But they still have nail district from the psoriasis. But it's just the milieu is favorable with all that hyper criticism the psoriasis for the fungus to go. Yeah lots of carrot and that's what I eat. I want to be around here. So as I said I do a lot of culturing and um sometimes K. O. H. Cultures the gold standard. And a lot of times I don't have time to do a in the in the clinic. Um It takes some time to do it. Um But sometimes I'll do both. I'll do a Q. H. In the clinic and then I have to send that dramatic culture out to the lab So you don't want to just put steroids on if you're not sure if something's a tenia like the top of this foot if you're like wait that could be always do sequential treatment. I've told you I've told many of you this many times don't do combination creams with traMADol and steroid. You do first the antifungal then do the topical steroid. And if the kid has eczema or psoriasis topical antifungal Zoran cream bases and and it's not bad for the the eczema or psoriasis for you to put a topical antifungal for two weeks it's two weeks and if it's a fungal infection it will clear up and then if they're still like something so they do have eczema psoriasis also coexisting and switch over to the steroid otherwise you can kind of hide the immune response to the tenia and get what we call Tenia incognito. Which is a dramatic fight infection that's been treated with topical steroid and it makes it worse, it spreads. And I've seen some pretty whopping cases um who have been on topical storage for a long time. So just to cover another couple of common nail problems and kids um Kids do get Canada all panicky but mostly that's an infants. Um It's mostly an adult problem. People do wet work like they cook and their hands are wet all the time. So if you see a red cuticle and you think it might be Canada you know ask about um wet hobbies having your hands and like fishing and things where you have your hands are wet all the time. Um So most of the para Nicaea we see are in toenails that are ingrown. Um And the solution to that is to never cut the nail down the nail fold to always try to cut it straight across. And they do make nail clippers that are 90 degrees at the top. So you don't want to get those nice curved ones that you use for fingernails, you wanna get a 90 degree nail nipper to use at home and go straight across the nail. Um And not down the side. So that's how you prevent ingrown toenails. We also get a lot of panic in our Accutane patients. Um And they can get staff and stuff but we manage them so you guys don't have to worry about that trauma of course is the number one cause of nail dystrophy and kids because they got their hands and feet and everything right. Um And sports and there's lots of ways to traumatize your nails. You know slam your finger in the corridors. The famous one. So um Subban goal hematomas are mostly managed in the E. D. And you guys do it. I don't I haven't done one of these in a long time but um I remember as a pediatrician using the paperclip heating it up and sticking in the nail. This is an example of using a punch biopsy to go through the nail plate and release the blood. Um It's one of those things like nurse maids elbows. It's very gratifying you can fix somebody like if you in two seconds they get relief from their pain. So one other nail problem. I was going to put the picture in but I didn't have time after you have a viral infection. You can have separation of the nail plate. Launch sorry horizontally from the nail bed. So you get a horizontal fisher and we call that viral Medicis and I've had a couple of good you know e consults lately um from the clinic. Um And you can get it's mostly after hand foot mouth. So even if they just have an inter viral infection and they don't have the rash you can get viral article and thesis. So the distal part of the nail comes lifts off and will shed. It really freaks their parents because it overnight shows up but it actually happens under the nail in the under the cuticle and then like a month or two later as it grows out they'll start to see the separation. So you have to go back a month or two and say you know did your kid have hand, foot mouth? Oh yeah it went through the daycare or yes he had the rash but even without the rash you can get it. So it's called viral Aniko Medicis. It's a post viral phenomena and it can happen like those lines or just a mild version of that which can happen with any federal illness. So anything with a fever, I tell people the body sees the nails and the hair as optional. So if you have a stressor like a high fever your nail growth is going to stop, your hair is going to stop growing, your hair is gonna go into resting face. So after that recovery like a month or two later you can see the nail um fisher and you can get hair fall which is diligent in which I'll talk about. So you don't have to worry about managing these rare nail problems and Children if you have a baby with nail dystrophy. Um There are genetic nail diseases congenital being one of the more common and then acquired nail dystrophy. Like 20 nail dystrophy. All the nails get pitted and dull. Some of those kids have eczema, some of alopecia areata and some have nothing else and it usually goes away but they need support and gentle nail, gentle skincare, things like that. So these these patients will want to be referred and we're happy to see them like implants is an urgent derm referral because like implants is a scarring nail disease and what it affects is this nail fold itself gets affected and the nail itself scars down the nail um matrix which is the place where the nail is made gets affected by scarring and then you basically destroy the nails. So it's very rare in kids. I mean I've just only seen a few cases, I just want you to be aware of it. Um You can't get permanent nail loss. It is fingers and toenails. So it's more like psoriasis in that sense. Um You see loss of the cuticle thinning of the cuticle. Um Redness of the cuticle, you can see here the cuticles get scaly um And we treat it with oral steroids. So this is a skin disease. We do pull steroids orally and the patients do really well. So you don't want to get to this point where the nails are destroyed and we treat mild cases with topical steroids in general like implants is more common in pigmented skin. Um Most of the studies are the series are from South Asia and most of what I've learned about like implant is clinically is from attendings from there and it's more common in both south asian and in black skin. And um so it's really good thing to be aware of. Likewise pigment pigment and nail streets are are common and pigmented skin. So um and the reason that there's so much anxiety about this including among attendings is that people with pigmented skin get more nail melanoma. Um and less like superficial spreading melanoma which is the number one melanoma you see in lighter skin tones. So there's awareness around nail melanoma. The good news is that it's extremely rare in kids. So I'll show you some pictures of melanoma under the nail and kids. But it's like just case reports. So the problem is that it's super rare but when you look at the skin signs the clinical signs and you're witnessing the changes that you're warned about could be signs of melanoma. It's really hard not to do a biopsy and the parents get really anxious to, so sometimes you just have to do a biopsy because you just cannot tell it to melanoma not clinically. So this is a seven year old girl I saw for a second opinion. She had a double nail streak that started as a single nail streak and the parents had photos they showed me and then when I saw her. so I had to come back in three months and I measured it and it was definitely wider, this is a damask api so I get out my magnifying lens, my dramatic scope and you can see that the nail streaks are different color, different width, summer a light brown summer dark. So she had a lot of variability in her pigment and nail streak. Um so you know which one is melanoma, This is from the paper about sub uncle melanoma and kids. This is the melanoma. So you could say, well there's these weird dots and global's here. Um there's you know a nail dystrophy here. So the nails actually chipping away, so that's different from your case. There's a lot of discoloration of the nail fold here, that's called Hutchinson sign, but this is a mole on right here and you can see there's discoloration there, that's called pseudo Hutchinson sign. So having the nail, the nail fold or the cuticle being brown is not a reliable sign of melanoma and kids. So this is a melanoma, this isn't, so ultimately um this is a melanoma and you could see all the different colors and and widths of the nail pigment and nail bands. This is dr cord or a slide and this is the six month old, so this was a little baby basically with almost a congenital melanoma and on the other hand conversely this is a study in of chinese kids, there was a big study and um they kind of took all comers to their dermatology clinic, a pigment and nail streaks. Um There were no melanomas and they biopsied many of them anyone that had a typical features. And this is what happens in your biopsy nails. So you're basically giving that person a permanent nail dystrophy. So they're never gonna have a normal nail. So that's why we agonize over the decision. So my point really to you all is if you have a pigmented nail street send it to us because it's hard to manage these, it's hard to decide what to do and just let us follow them and it's rare enough that you know, you're not gonna overwhelm us with your referrals. Um Another term for this is longitudinal Melanie Kia because it runs a longitudinal along the axis of the nail. Um Melanie Melanie Nicaea means pigmented nail. So I think we think all kneel nearby and pigmented streets just send them to us. Sometimes you don't know if it's a mole or it's a medication or if it's normal physiologic pigmentation of the nail bed. Um One way to kind of tell the difference between physiologic and drug versus mole is moles and melanomas tend to be one nail, whereas physiologic, pigmentation and drug induced like a mini cycling induced pigmentation of the nail tends to be multiple nails, fingers and toes. Okay, so we're gonna shift gears from nails to hair hair loss is very emotional. Um we're gonna talk about it sort of from start to finish. So in infants that are born with alopecia patches, there's a very small differential. So that's the good news. Um The most common cause is um Niva sebaceous, so that's a really common birthmark which is basically the nail hail, sorry, gonna switch from nails to hair. The hair follicle is replaced with a hematoma, which is just basically normal tissue, but too much of it in the wrong place. So uneven sebaceous is um this is sebaceous glands have replaced the hair follicles. So this will never have hair at birth because of maternal androgens, they're often yellow and pebbly. And then as the kids get older they flatten and become smooth. And then when they go into puberty they get they get pebbly again and sometimes even wordy and hypercar topic and they start getting irritated and catching on the comb. So 2030 years ago we used to tell people all of these need to be taken out. But as more studies came in, it became clear that the risk of getting skin cancer need a sebaceous is so low as to be almost non, existent. we still counsel families if there's any changes, any bumps showing up on it to come in and we'll go ahead and biopsy and sometimes if the bumps are the area that's changing as big, we'll just get the whole thing. Excised and I send them the plastic surgery because they're usually pretty big. Um But you don't have to take all night to sebaceous out. There are case reports of metal like metastatic carcinoma etcetera. But it's so rare. And um so the family is like, no, we don't care about this, we don't want to take it out, it's fine. As long as a kid knows as they go into adulthood that they should, they feel something different that needs to be examined. So that's really common. Um Probably second on the list is a pleasure, cutest congenital to those usually show up as round, smooth, sometimes scabby at birth and then just thin skin scar like um alopecia patches. So those also never grow here because of a pleasure cutest. The skin just didn't form, right and the hair falls just aren't there. Um So that's something that can be there for birth. And you we image the ones that are midline or have any other skin signs or thick hair around them. Um That's in my birthmark, stock, triangular alopecia. For some reason people don't usually notice it until the kids are older because you know, a lot of times babies don't have that much hair, especially on the side. So as they go into toddler years, the parents will start to notice, wait a minute, There's like this area that doesn't grow hair and those will never grow hair, we don't really know what causes triangular alopecia, but it's probably some kind of somatic mutation of a growth factor and something, whatever makes the hair follicles develop, it doesn't have any associations. It's always on the parietal scalp, although I did see one that was more in the frontal scalp and I was like, is this triangular alopecia? But it looked like it. And it's usually kind of a triangular shape, which you can't really see in this photo. It's a little bit narrow at the top than the base. And then the gino dermatologists again, if you've got nail problems, hair problems, dry skin and the kids, kids not thriving, then they could have a geno Dermot oh, sis. And that requires both genetics and dermatology and testing and stuff like that. So just be aware of it. So to summarize and infants and toddlers, probably the number one cause of patchy hair loss is something you see in almost every baby, which is after they're born, they shed their hair, many of them shed it completely. And then they grow it, they're kind of regular hair back in really uneven pattern. So you get the hair around here or the mohawk and that's really a cute little phenomena. You see between, you know, six months and a year and a half and sometimes even a little bit longer for the hair to grow in. So here's an example of a mohawk, um you can see alopecia aryan in infants. And if it presents more earlier than one year of age, then that's a worse prognosis for lifelong involvement. You can see tiny capitals even as early as two weeks of age. And that would be kind of scaling. So there'd be scalp changes. Hair pulling disorder. You can see in toddlers and sorry in preschool age rare and toddlers and not in infants and likewise traction. Alopecia usually don't start seeing until preschool from hairstyling. With pretty much with older kids, school age and teenagers. It's all pretty much the same causes. Um With some exceptions it's very emotionally difficult to have a hair loss problem um at any age but especially after age three when you have more self awareness it's emotionally loaded. And there might be a hidden agenda like a family member who had either alopecia areata or and or genetic alopecia. So even a little bit of hair fall can cause panic. So the most common scenario is um usually girls more than boys because their hair is longer and they notice it. The hair fall increase hair fall in teenage girls. The most common hair loss visit. So you have to go back 3 to 6 months. Like the nails look for the trigger that could have put the hair into the resting phase two cause intelligent flutie. Um The most common cause used to be OCP. So some of the other long acting agents don't cause tillage influence because they don't um impact ovulation as much. But theoretically with any um like an I. E. D. You could get up till but we see it more with the birth control and with pregnancy, even a pregnancy that doesn't carry to term fever is really common. Any sort of acute illness. And covid 19 is a huge trigger of intelligent effluvia in um any kind of surgery, even just a routine surgery can do it. Um And any kind of weight loss. So if a child is intentionally or unintentionally lost weight um it can cause hair loss if you have wacky um cycles. If you have secondary Maria. I saw a kid yesterday who had kind of regular cycles. And then now is having really irregular cycles and she's she's having increased shedding. So um that's something if it gets really bad you can do the birth control pill. Um But you know that's kind of kind of a primary criticism. Joint decision making with the kid. Family history is not really relevant for tillage enough, lovey. Um But you want to find out about androgenic alopecia because if a teenage boy or a girl gets a teenage Teligent effluvia mit can unmask an androgenic alopecia that was going to present like five years later. So your first question is is your hair falling out more or you're seeing patches of alopecia, that's where I tell the residents that's where you have to start most of the time it's my hair is falling out, You look at the kid, you're like that kid has more hair than I do and then you talk to them about Children effluvia and you do the history and um and sonia, somebody help me make this table. So I want to give her credit. She's not, she was appeal to at the time, she's not anymore. So basically this is gonna be the most common cause of that scenario. The hair goes into the resting phase instead of the growing phase, which is again, the resting phase is um tillage in and then it falls out. So usually last 36 months and the new hair will push out that tillage interesting hair which has a little white bulb on it. You can ask the kid just collect the hairs and look for the white bulb. It also happens in new mothers. So sometimes if the baby has that the kid had, the mom has it. But the baby you don't usually notice because the hair is short and likewise, boys don't usually present unless they have long hair. So directly address the elephant in the room, which is, you know, find out if there's a hidden agenda, make sure they know it takes a month for the hair to even show up at the scalp and then it grows a centimeter a month. So they've got really long hair, it's going to take forever to the hair to get thick again and if it makes them anxious, they can cut their hair and it won't take as long, You can use minoxidil topically once a day at night if they're if they feel like they're seeing the scalp surface and they want to do something but you don't have to treat it. So um through history look for stressors, physiologic stressors and then the history we talked about and if you don't really get any of this and you look and you're like, yeah, this kid really does have hair thinning. Um I can see the scalp and I know they show you pictures then this is kind of my hair loss work up. I don't do cbc's necessarily but you can but it is more sensitive for iron deficiency. So I usually just do for written vitamin D. Level because vitamin D. Deficiency can cause hair loss from systemic disease. Any kind of thyroid problem, hyper or hypo eating disorders, lead poisoning and then good review systems for room in logic disease. I don't do a and A is because you get the red herring and sometimes I'll do hormone levels if there's other signs of PCO like um basically too much hair in certain places and it can post a sniper cans with visible alopecia. You will see this at all ages. Tina capitals with the scaling. You can see the hair loss here in scaling again that strike of frightened friend of ours is the most common um organism. And usually it's person to person. You can see no black dots, you can see inflammation, You can see really total hair loss, it looks scarred, You can see pustules and you can sometimes see a Ganapathy. So I have a very low threshold for doing cultures, especially in our population. It's more common and curly hair. So but you see it in all different kinds of hair. So just have have to have a high level of suspicion if it's smooth alopecia. The most common cause of smooth visible hair loss is alopecia areata. It's immune mediated and associated with a toupee vitiligo and thyroid disorders. You can do screening if there's other signs of these problems but you don't have to do screening tests of review systems is negative. 25% of these kids will have a family history again to the point of asking about family history and most of them you get one patch and it re grows and you're done. A significant minority. Go on to have chronic patch type and a very tiny tiny number will get Totalus or Universalist, which is hair loss all over the body. We usually treat with topical steroids sometimes I use these other things but you guys don't have to worry about that. Usually these parents want a referral and we're happy to see them but you can start topical steroids even just like try and sit alone cream while you're waiting. And um oral JAK inhibitors are um now being studied in kids. There are FDA approved for adults and I've been able to send some teenagers to hear experts to get JAK inhibitors. I've got two patients now and JAK inhibitors which work really well for alopecia Areata totalus and universal Alison are pretty life changing as you can imagine. Hair pulling disorder is not common, but it can be a habit in younger kids like this and be a sign of more of a mental illness and teenagers and it's associated with eating disorders and can be very um intractable and difficult to address. A lot of times. There's no insight. It can't like the parents deny it and the kid denies it in the case of older kids. Um now we call these body focused repetitive behaviors, not trichotillomania or skin picking. Usually we call hair pulling disorder instead of trichotillomania. And so the most common age is kind of that junior high set perry pure. It'll um again, it's associated mental health issues. So that's maybe why it happens. Then the alopecia is you're usually really patchy and irregular and moves around. Um this kid had autism spectrum disorder. So that is an association, um, it's kind of a stress relief behavior for Children with autism. So hair pulling disorder, you usually see visible visible hair loss that's irregular with alopecia areata. It's very smooth and well defined, Well demarcated and tiny capital could kind of be anything, but you definitely usually have scale, you're looking for scale. Um, sometimes the androgenic alopecia patients will present in adolescence and in girls it's frontal just the whole frontal scalp will thin and and that part widening. And boys you get the same findings as adults which is vertex and lateral frontal hairline recession. So can present in normal teenagers and be normal and not Bp ceo and not be a hormone problem. And boys, here's an example of early energetic alopecia unfortunately comes from both sides of the family. So this whole thing that if your mother doesn't have hair loss then you won't have it is not true. I mean your father, it can be either palla genic and I start treatment with topical minoxidil and the new thing is people are using oral minoxidil for hair loss of all kinds people meaning dermatologist. So if you see one of our patients on oral minoxidil it's very safe. We use low doses at that time. Um and it does really help the enter genetic alopecia is that are more severe and present earlier. I don't use oral finasteride under the age of 18. I'm not comfortable with that. I don't think we have good enough long term studies. It's used more in adults but I do use a lot of Rogaine and girls spironolactone is actually really helpful but you have to use super high doses so a lot of times we'll put the kids on the OCP spironolactone combo traction alopecia is common with styling people with curly hair that braid and even ballerinas that pull back in tight buns chronically. You can scar the hair follicle by pulling um curly hair itself is really fragile and breaks more easily. It's really dry. So it tends to break more easily and you tend to get more alopecia for the same styling. Um so it's difficult to counsel around this, but an open ended discussion um usually will help prevent the permanent hair loss. Um I am a fan of natural hairstyles and I know that's easy for me to say, since I have straight hair and I understand why people with curly hair style. Um plus it's very attractive and it's very cultural and it's a very individual decision and there's no judgment. It's up to the person how they want to style. It's just education about how to style. Um and if you have curly hair, those of you out there that have curly hair, you don't wanna wash it a lot and post very drying. So you want to do minimal hair washing, which of course if you're a teenager and you can't wash your hair a lot, you get more dandruff. So there's a little bit of a balance there. But um I'm not a big fan of curly hair, people washing their hair a lot because it breaks, it gets dry. That's kind of the whole spectrum from the babies born with hair loss to the teenagers one little sub category that is relatively rare but can show up in your toddler. So these are the 3 to 5 year old kind of preschool age is loose. And again syndrome, which is an inherited weakness of the hair shaft. So it's a growing hair that breaks, so usually um in the hair straight. Okay, so it's not curly and it's not from styling, it spontaneously breaks just from running a brush through your hair. Usually these kids have blonde hair, I have seen it in brown hair. The hair looks unruly frizzy, lust, earless and doesn't grow. So the families will come in when the kids three or four and say, my kids here just doesn't grow. I never cut it and it's this short again, this is a problem that only presents in girls unless you know the boy has long hair, but usually the parents don't complain about that so much. I don't treat this. I counsel, I have them not do a lot of styling and it spontaneously improves them by school age. Use their hair grows still scarring alopecia, like, like implants, which is scarring in the nails. Really, really rare in kids, fortunately, um you can see discord lupus on the scalp and you'll see redness and dis pigmentation. Um If the kid has subcutaneous lupus or lupus in the fat layer, they can get nodules and scarring and then final finally more fia, which is usually you'll see something going down the forehead, but if it goes up into the scalp, you'll have a line of alopecia coming straight from the forehead. So look really carefully at the forehead for a discolored area or kind of you can see the thinning here texture change. And this is an urgent referral because they need systemic therapy both room and we co manage them skating rink means it's really smooth. So fortunately scarring alopecia in Children is rare and that's the good news. The bad news is it's it's permanent. So you got to get them in quickly so to summarize refer any nail dystrophy that um results in dysfunction pain with movement or activity. Um If the patients really self conscious about it that's a legit reason to send. Um Or if you see any effect on the cuticle um where it looks like it's thinning. But any bad nail just for you should send pigment and nail strips. We talked about scarring, alopecia or alopecia or hair loss is affecting the patient's socially or otherwise you can start the initial evaluation, do your good history, you can start you can do labs um You can address nutritional issues if you've got a picky eater and they're losing weight or you have a eating disorder. We need you guys to manage those patients because we can't manage that we don't have time. And then if you think it's intelligent effluvia and you have a source of it. Just reassure tell them the hair's gonna grow back in 3-6 months. So after 3-6 months it'll stop falling out and the hair will grow back to where it was before. So um this is the hardest part of the talk for me. I am retiring in january and I know that people are talking about it. I had somebody come up to me in the stairwell yesterday so I just want to come out and tell everybody at the same time that I will be retiring in january um to spend more time with my family and um as you know I'm not gonna leave you completely so it's not the end. I'm gonna come back and teach part time and I'm gonna be around but probably in the winter I'll be gone for a couple of months and I'll come back in the spring. So I want to end this talk by thanking my team that we built from Anjali and I and one office assistant to this incredible group of people that take such good care of our patients. Um Not just my wonderful associate Nicole Hitler who has taken over a section chief and RC ahmed who has taken over as education chief. My P. A. Angela Washington who's my one of my best buddies at work and my R. R. N. LINh who does photo therapy but our whole crew we have to L. V. N. S. Now and a couple of office assistants. So we've built an incredible team with you guys support. Um We'll keep taking care of your patients. I will still be around and I'm here until the holidays. So you don't have to say goodbye to me yet. I hate goodbyes, so don't say goodbye to me and now I can take questions but not about retirement. Thank you. Thank you so much. That was a whirlwind end. Thank you Doctor Howard. Really high yield, really extremely helpful talk. We have a lot of questions, we'll try to get through as many as we can. Um So one of these questions, have you seen discoloration of nails? I think this is like beyond the moles and the melanomas that you in that are within normal for people of different skin tones. Yeah, so um the more melon and you have in your skin, the more melanin you can have in the skin under your nail and it shows through the nail. So yeah, you can have a uniform um darker skin or it can be a little bit uneven and it can be, you know, some nails, but usually it's more than one nail, but it can start and when they like when you see a child who's eight or nine, sometimes it it happens a little bit later. So pigmentation, like when when babies are born, usually they don't have any pigmentation under their nails. And as they get older, you wonder, you know, is that sun exposure, like you get sun on the skin around the nail and you can get actually tanning of the nail bed. So yeah, that can be, it can be a normal variant with pigment. Yeah, great. Um This is another great question. Should we remove Niva sebaceous lesions for patients who are neuro diverse and largely non speaking, since they may not notice changes and or be able to express to others that they feel a change. And if so, is there an ideal age to do it given that many developed language later on? Um So you don't have to, if there's any kind of caregiver in, in the person's life, they can take a look at it as part of their skin care. Um and if they see a change, they can deal with it. Um If it seems to bother the patient because they can get itchy, the ideal time to take them out, I say is junior high to high school. So I tell the parents this is like wisdom teeth and they can bother the patient. So even if the patient's nonverbal, if it seems to be crusted or it looks inflamed Or they're doing any behaviors that make you think it's bothering them, then the best time to take it out junior high high school surgically, it's probably easy in infancy, but then you have more in seizure risk. So on balance around puberty, when it starts to thicken is when I tell people to send the plastics between 12 and 18 anytime. Okay. And could you speak to psychlo products um and patients that may feel like it's worthwhile despite the cost. Uh Yeah I mean maybe it's slightly better than topical Truman. If I mean if you if you're patient has access to it through their insurance, I don't have a problem with it at all. To nail polish. Maybe it's slightly more efficacious. It is an adults but in kids maybe a little bit um It's just funny a lot of my patients don't have access to it so I don't use it very much. But if you if you do have access to and you're using I think it's a fine first step. Yeah it's gonna work better in the kids than adults. So. Okay I'm just not a lot of studies but I don't have any objection to it. Okay. And another medication question, what are your thoughts on supplements? Like over the counter supplements such as biotin or keratin for hair and nail growth thumbs down. Okay. So I'm sorry but the american diet is not deficient protein. You guys know I don't like supplements. So um the biotin thing is that there's the data is terrible. Um Yeah I'm I'm yes on iron and vitamin D. You know that's a whole nother topic right? But somebody's got a load of vitamin D. Level. Yes they should supplement vitamin D. And they should probably get a little bit of sun, especially if they're a low risk for skin cancer, they should you know if they have black skin, they should get more sun if their vitamin D. Levels are lower or darker skin, it's hard to get vitamin D. Through pigmented skin. Um But by this whole thing that the data is like non existent and it's a waste of money. So I'm not a fan, it's much more important. Especially if you have dry skin and you wash your hands 50 times a day. Hello doctors out there, nurses P. S. Everybody. It's more important to moisturize your hands your fingers than to take biotin. Just slather them with Vaseline every single night and your nails will grow up better and skip the biotin. You know, for alopecia Ariana. Um Just confirming that it is okay to use transit alone to the head. That there's a traditional teaching to kind of avoid stronger steroids in the head region. Okay, so that's backwards. The scalp is super thick. Anybody who searched the scalp wound sutured the scalp wound, you know how thick the scalp is, so we rarely see atrophy in the scalp. You gotta be careful if you're here because you're pretty close to the face. Um So I tell people go back an inch at least. Um But it's super safe to use topical steroids on the scalp and doesn't work that well. It doesn't work great but it helps a little maybe. I mean cause you know the disease is way down on the hair follicle. Um But I think it's safe and I use it. I use topical steroids for scalp scalp psoriasis and I just don't see atrophy you know I look at patients and I'm looking for it and I don't see it so I don't know where that teaching comes from but it's wrong. Yeah I I remember I had a patient in the urgent care that I called you about and you said go ahead and start the transit alone on the scalp. It's going to take them a few months to get in and it's totally safe. And then we'll do the interregional injection. Yeah and there is another question just about um he consults how how can we access E consults. So we're working on the outpatient E consults basically. I've told like those of you who work at Children's and you have a clinic patient that needs help. Um To staff message me um Nicole did a lot of work on the inpatient consult order. And epic so now even if you can just order inpatient dermatology e console um and you can even do an urgent care patient and then they'll get a written note. It may not be the instantaneous. I mean if it's really an emergency you know you have to call us but revolt es or pages um But you know there's very few hair nail emergencies. So you do the primary stuff I talk about in this lecture if you want the slides I can share box with you just don't share the identifying images. Um and put in that. Usually the referrals take awhile so the initial measures are really good to know about. Um But we hopefully will have an outpatient e console option for you guys, it's official. So any inpatient that includes er you can order a consult or you got somebody at summit who's in for something else and they've got eczema and you're like, I don't know what to do with this. You can send an inpatient consult and it shows up on our inbox. If it's something that it's kind of relatively urgent, shoot us a volte and say hey we put in the console. It doesn't I don't really get them in my inbox, I guess Nicole does. So just just let me know the timing on it when you want me to do it and then you'll have a written note. Okay, perfect. One more question about alopecia going back to steroid use um this from Noemi Spin Nazi, she was wondering if club is all is okay to use on kids with Down syndrome before like to start that they're sent in to see you. Yeah, if you No, no Amy or somebody who's working in a more specialty clinic. Uh So kids with Down syndrome get more alopecia Areata. Like they get more some other autoimmune stuff and AMy's talk on skin problems and um Down syndrome is so excellent. Um Anyway, yes you can use it as all if you're again I just warn people about being close to the face but if you're back here yeah you can use it at all. Um and maybe refer them because we want might want to co manage with you and I didn't talk about oral steroids with alopecia areata. But if you guys have a patient you send to like a hair clinic and they do pull steroids orally, that's now on the docket along with oral minoxidil. So I like the pediatricians to know what the terms might be doing that because they're like why are they doing that? Um It's good to know. Yeah. Okay. Well it is nine am sorry we didn't get to all the questions but we did have a couple of additional comments that just says thank you Renee you are the best. Congratulations and thank you. And remember you guys can email me Renee dot howard at UCSF dot E D U. If you didn't get your question answered and if you want the slides you can send me an email and I will get them to you. Thanks everyone, see you later. Good day Created by
