Hair and Nail Disorders

Different types of Hair Loss

There are different types and reasons of Hair Disorder:

  • Telogen effluvium (normal hair loss)
  • Androgenetic Alopecia (male and female pattern)
  • Alopecia Areata
  • Folliculitis Decalvans

Telogen Effluvium (Normal Hair Loss)

It is normal to shed approximately 30-150 hairs from our scalp daily as part of our hair cycle, but this can vary depending on washing and brushing routines. Hair regrows automatically so that the total number of hairs on our head remains constant. Telogen effluvium occurs when there is a marked increase in hairs shed each day. An increased proportion of hairs shift from the growing phase (anagen) to the shedding phase (telogen). Normally only 10% of the scalp hair is in the telogen phase, but in telogen effluvium this increases to 30% or more. This usually happens suddenly and can occur approximately 3 months after a trigger.

Increased hair shedding in telogen effluvium occurs due to a disturbance of the normal hair cycle. Common triggers of telogen effluvium include childbirth, severe trauma or illness, a stressful or major life event (such as losing a loved one), marked weight loss and extreme dieting, a severe skin problem affecting the scalp, a new medication or withdrawal of a hormone treatment. No cause is found in around a third of people diagnosed with telogen effluvium.

Telogen effluvium usually resolves completely without any intervention as the normal length of telogen is approximately 100 days (3 to 6 months) afterwhich period the hair starts growing again (anagen phase). However,depending on the length of the hair, it may take many months for the overall hair volume to gradually return to normal. Telogen effluvium can return, especially if the underlying cause is not treated or recurs, and would be called chronic telogen effluvium if lasting more than 6 months.

Androgenetic Alopecia (male pattern)

Male pattern hair loss (MPHL) is the most common type of hair loss in men. It is also known as androgenetic alopecia. It affects about 50% of men over the age of 50.

MPHL is caused by a combination of genetic and hormonal factors. A hormone called dihydrotestosterone (DHT) causes a change in the hair follicles on the scalp. The hairs produced by the affected follicles become progressively smaller in diameter, shorter in length and lighter in colour until eventually the follicles shrink completely and stop producing hair.

Yes. It is believed this can be inherited from either or both parents.

Men can become aware of scalp hair loss or a receding hairline at any time after puberty. There are usually no symptoms on the scalp. Hair loss may cause significant psychological difficulties.

The usual pattern of hair loss is a receding frontal hairline and loss of hair from the top of the head. Hairs in the affected areas are initially smaller in diameter, and shorter compared to hairs in unaffected areas, before they become absent.

The diagnosis is usually based on the history of scalp hair loss on the front/ top of the head or receding hairline, the pattern of hair loss and a family history of similar hair loss. The skin on the scalp looks normal on examination. Occasionally blood tests may be carried out.

No, there is no cure. However, it tends to progress very slowly, from several years to decades. An earlier age of onset may lead to quicker progression.

Licensed topical and oral treatments:

  • Applying 5% minoxidil liquid or foam to the scalp may help to slow down the progression of hair loss and partially restore hair. The liquid or foam should be applied to the affected scalp (not the hair) using a dropper or pump spray device. It should be spread over the affected area lightly and does not need to be massaged in. Minoxidil can cause skin reactions such as dryness, redness, scaling and/or itchiness at the site of application and should not be applied if there are cuts or open wounds. It needs to be used for at least 6 months before any benefit may be noted. Any benefit is only maintained for as long as the treatment is used. Minoxidil solution may cause an initial hair fall in the first 2-8 weeks of treatment, and this usually subsides when the new hairs start to grow.
  • For men, finasteride tablets reduce levels of dihydrotestosterone(hormone), which may slow hair loss and possibly help regrowth of hair. Continuous use for 3 to 6 months is required before a benefit is usually seen. Decreased libido and erectile problems are recognised side-effects of this treatment. Any beneficial effects on hair growth will be lost within 6 to 12 months of discontinuing treatment.

It is important to note that all of the topical and oral treatments only work for as long as the treatment is continued.

Wigs and hair pieces:

  • Some affected individuals find wigs, toupees and even hair extensions very helpful in disguising hair loss. There are two types of postiche (false hairpiece) available to individuals; these can be either synthetic or made from real hair. Generally, only synthetic wigs are available under the NHS. Synthetic wigs and hairpieces, such as a toupee, usually last about 6 to 9 months, are easy to wash and maintain, but can be susceptible to heat damage and may be hot to wear. Real hair wigs or hairpieces can look more natural, can be styled with low heatand are cooler to wear.

Skin camouflage:

  • Spray preparations containing small pigmented fibres are available from the internet and may help to disguise the condition in some individuals. These preparations however, may wash away if the hair gets wet i.e. rain, swimming, perspiration, and they only tend to last between brushing/shampooing.

Surgical treatments:

  • Surgical treatment is not offered under the NHS. This can be sought privately. Surgical treatment includes (i) hair transplantation, a procedure where hair follicles are taken from the back and sides of the scalp and transplanted onto the bald areas; and (ii) scalp reduction, where a section of the bald area is removed and the hair-bearing scalp stretched to cover the gap. Tissue expanders may be used to stretch the skin.

Androgenetic Alopecia (Female pattern)

Female pattern hair loss (FPHL) has also been called androgenetic alopecia. It is the most common type of alopecia (hair loss) in women and the severity can vary.

FPHL is caused by a combination of genetic and hormonal factors. The hairs produced by the affected follicles become progressively smaller in diameter, shorter in length and lighter in color until eventually the follicles shrink completely and stop producing hair. FPHL can be associated with conditions in which androgen (a group of hormones) levels are elevated such as polycystic ovarian syndrome (PCOS). Acne, increased facial hair, irregular periods and infertility are all signs of PCOS.

Yes. It is believed that it can be inherited from either or both parents.

In women, the age of onset is later compared to male pattern hair loss, usually occurring in the 50s or 60s. Occasionally, FPHL in women may start earlier than this, in the 30s or 40s. FPHL is not usually associated with any scalp symptoms. Hair loss can, however, cause psychological consequences and have an impact on quality of life.

Patterned hair loss looks different in males and females. In females, there is widely spread thinning of the hair, mainly on the crown of the scalp. The hairline at the front of the scalp often remains normal. Hairs in the affected areas are initially thinner (smaller in diameter), and shorter compared to hairs in unaffected areas, before they become absent.

The diagnosis is usually based on the history of gradual thinning of hair or increased hair shedding on the top of the head, the pattern of hair loss and any family history of similar hair loss. The skin on the scalp looks normal on examination. Occasionally blood tests may be carried out.

No, there is no cure for FPHL. However, it tends to progress very slowly, from several years to decades. An earlier age of onset may lead to quicker progression.

Topical and oral treatments:

  • Applying 2% or 5% minoxidil solution to the scalp every day may help to slow down the progression and partially restore hair in some women. Only the 2% strength is licensed for women but it is not available under the NHS; the 5% minoxidil solution can be used under the advice of a medical doctor, but it is not available on NHS prescription and is expensive. Minoxidil solution should be applied to the affected scalp (not the hair) using a dropper or pump spray device and should be spread over the affected area lightly, it does not need to be massaged in. Minoxidil can cause skin reactions such as dryness, redness, scaling and/or itchiness at the site of application and should not be applied if there are cuts or open wounds. Minoxidil solution should only be applied to the scalp. Any spillage to the forehead or cheeks should be cleansed to avoid increased hair growth in these areas. Minoxidilshould be used for at least 6 months before any benefit may be noted. Any benefit will only be maintained for as long as the treatment is used.Minoxidil solution may cause an initial hair fall in the first 2-8 weeks of treatment, and this usually subsides when the new hairs start to grow.
  • Oral treatments such as spironolactone, cyproterone acetate, flutamide and cimetidine can block the action of dihydrotestosterone (a hormone)on the scalp, which may lead to some improvement in hair loss. These treatments are not licensed for use in FPHL. Spironolactone and cyproterone acetate should be avoided in pregnancy since they can cause feminisation of a male foetus; both should be avoided during breast feeding. Flutamide carries a risk of damaging the liver. It is important to note that all of these topical and oral treatments only work for as long as the treatment is continued. Wigs and hair pieces:
  • Some affected individuals find wigs, toupees and even hair extensions can be very helpful in disguising FPHL. There are two types of postiche (false hairpiece) available to individuals; these can be either synthetic or made from real hair. Generally, only synthetic wigs are available under the NHS. Synthetic wigs and hairpieces, usually last about 6 to 9 months, are easy to wash and maintain, but can be susceptible to heat damage and may be hot to wear. Real hair wigs or hairpieces can look more natural, can be styled with low heat and are cooler to wear.

Skin camouflage:

  • Spray preparations containing small pigmented fibres are available from the internet and may help to disguise the condition in some individuals. These preparations however, may wash away if the hair gets wet (i.e. rain, swimming, perspiration), and they only tend to last between brushing/shampooing.Surgical treatments:

Surgical treatment is not offered under the NHS. This can be sought privately. Hair transplantation is a procedure where hair follicles are taken from the back and sides of the scalp and transplanted onto the bald areas.

Alopecia Areata

Alopecia is a general term for hair loss. Alopecia areata is a common cause of non-scarring (does not cause scarring to the scalp) hair loss that can occur at any age. It usually causes small, coin-sized, round patches of baldness on the scalp, although hair elsewhere such as the beard, eyebrows, eyelashes, body and limbs can be affected. In some people larger areas are affected and occasionally it can involve the whole scalp (alopecia totalis) or even the entire body and scalp (alopecia universalis).It is not possible to predict how much hair will be lost. Regrowth of hair in typical alopecia areata is usual over a period of months or sometimes years, but cannot be guaranteed. The chances of the hair regrowing are better if less hair is lost at the beginning. Most people, with only a few small patches get full regrowth within a year. If more than half the hair is lost then the chances of a full recovery are not good. The hair sometimes regrows white, at least in the first instance. Most people get further attacks of alopecia areata. In alopecia totalis and alopecia universalis, the likelihood of total regrowth is less.

Hair is lost because it is affected by inflammation. The cause of this inflammation is unknown but it is thought that the immune system, the natural defence which normally protects the body from infections and other diseases,may attack the growing hair. Why this might happen is not fully understood, nor is it known why only localised areas are affected and why the hair usually regrows again. Someone with alopecia areata is slightly more likely than a person without it to develop other autoimmune conditions such as thyroid disease, diabetes, lupus and vitiligo (white patches on the skin), although the risk of getting these disorders is still very low. If you have other symptoms then discuss these with your doctor. Your doctor may suggest a blood test. Alopecia areata is not catching and no connection has been made with food or vitamin deficiencies. Stress occasionally appears to be a trigger for alopecia areata, but it is possible that this link may be coincidental as many of those affected have no significant stress.

There is a genetic predisposition to alopecia areata. About 20% of people withalopecia areata have a family history.

No, alopecia areata cannot be cured. Depending on the extent of hair loss there is a good chance that, for 4 out of 5 affected people, complete regrowth will 4occur within 1 year without treatment. There may, however, be further episodes of hair loss in the future. If there is very extensive hair loss from the start, the chances of it regrowing are not as good. Those with more than half the hair lostat the beginning or with complete hair loss at any stage have only about a 1 in 10 chance of full recovery. The chances of regrowth are not so good in young children and those with the condition affecting the hairline at the front, side or back.

People with mild early alopecia areata may need no treatment, as their hair is likely to come back anyway without it. Some treatments can induce hair growth, though none is able to alter the overall course of the disease. Any treatments  that carry serious risks should be avoided, as alopecia areata itself has no adverse effect on physical health.The treatments that are available include:

  • Steroid creams and scalp applications. These are applied to the bald patches, usually twice a day, for a limited time.
  • Local steroid injections. These can be used on the scalp and brows, and are the most effective approach for small patches of hair loss. Injection scan be repeated every four to six weeks and are stopped once regrowth is achieved.
  • Steroid tablets. Large doses of steroid tablets may result in regrowth of the hair, but when the treatment stops the alopecia often recurs. Taking steroids by mouth over a period of time can cause many side effects including raised blood pressure, diabetes, stomach ulcers, cataracts and osteoporosis as well as weight gain.
  • Dithranol cream
  • Contact sensitisation treatment
  • Ultraviolet light treatment (PUVA).
  • Minoxidil lotion.
  • Immunosuppressant tablets. These tablets include sulfasalazine,methotrexate, ciclosporin, and azathioprine. They suppress the immune system, and are occasionally used to treat severe alopecia areata which have not responded to other treatments. The evidence that they can cause hair regrowth in alopecia areata is limited and these tablets can have potentially serious side effects.
  • Tofacitinib and ruloxitinib are potentially new immunosuppressive treatments for alopecia areata. These treatments are not yet available as further studies are needed to confirm theirs beneficial effects for alopecia areata.

Different types of Nail Disorder

There are different types and reasons of Nail Disorder:

  1. Fungal infection of the nail
  2. Abnormal-looking nails
    • Beau’s lines
    • Longitudinal ridging
    • Pitted nails
    • Clubbing
    • Koilonychia
    • Nail-patella syndrome
  • Green nails
  • Blue nails
  • Black nails
  • Leukonychia (white nail)
  • Yellow nail syndrome
  • Yellow or yellow/white nails without thickening or onycholysi
  • Ingrowing toenai
  • Onycholysis
  • Onychogryphosis
  • Median nail dystrophy
  • Splinter haemorrhages

Fungal infection of the nail

Fungal infections of the nails are also known as dermatophytic onychomycosis, or tinea unguium. The responsible fungus is usually the same as that that causes athlete’s foot – a common infection of the skin of the feet, especially between the toes. In athlete’s foot the responsible fungus lives in the keratin that makes up the outer layer of the skin. When the fungus spreads to the keratin of the nails, the result is a fungal nail infection.

Fungi spreading from athlete’s foot (known as ‘dermatophyte fungi’) cause most fungal nail infections. Less often a nail infection is due to other types of fungi, usually yeasts (eg. Candida) and moulds which do not cause athlete’s foot. These other fungi tend to attack nails that are already damaged, as it is easier for the fungus to invade. Fungal infections of the toenails are very common (1 in 4 people can be affected at a given time), those of fingernails less so. Both are seen most often in the elderly, those with impaired immune systems, and in people with diabetes and poor peripheral circulation. Warm, moist environment helps fungi to grow and cause infection. Wearing occlusive footwear or using shower stalls, bathrooms or locker rooms can increase the risk of fungal infections.

When fungi infect a nail, they usually start at its free edge, and then spread down the side of the nail towards the base of the cuticle. Eventually the whole nail may be involved. The infected areas turn white or yellowish, and become thickened and crumbly. Less commonly there may be white areas on the nail surface. The nails most commonly affected by fungal infections are those on the big and little toes. Sometimes, especially in those who carry out regular wet work such as housewives or cleaners, the skin around the fingernail becomes red and swollen. This is called paronychia, and can allow infection to get to the nail.

Fungal nail infections are usually diagnosed clinically.

Yes. However, to successfully cure fungal toenail infection requires long treatment and may take up to a year. Fingernails are easier to treat. Fungal nail infections commonly recur, especially on the toes.

Fungal infections of the nail do not clear up by themselves, but not all of them need treatment. It is important to treat people whose infections may cause significant health problems such as those with diabetes or immune suppression, in order to prevent potentially serious health problems.

Treatment options include:

Treatments applied to the nail (topical treatments)

  • Treatments applied to the nail work less well than those taken by mouth. They are most effective if the infection is treated at an early stage. The treatments used most often are amorolfine nail lacquer and tioconazole nail solution. Alone, they may not be able to clear the deeper parts of an infected nail, though regular removal of abnormal nail material with clippers or filing can help with this. Used in combination with an antifungal remedy taken by mouth, they increase the chance of a cure. They may have to be used for a period of 4 to 12 months before a response is noted. The course of treatment is shorter for fingernail infections. The cure rate with topical agents alone, is low, approximately 15-30%. Topical treatments are safe. Local redness and irritation can occur.

Treatment by mouth (oral treatments)

Before starting on tablets, the doctor should send a piece of the nail to the laboratory to check that the diagnosis of a fungal infection is confirmed. Three medicines are available for use in fungal nail infections:

  • Griseofulvin
  • Terbinafineand itraconazole
  • Fluconazole

Laser treatments.

No, there is no cure for FPHL. However, it tends to progress very slowly, from several years to decades. An earlier age of onset may lead to quicker progression.

Topical and oral treatments:

  • Applying 2% or 5% minoxidil solution to the scalp every day may help to slow down the progression and partially restore hair in some women. Only the 2% strength is licensed for women but it is not available under the NHS; the 5% minoxidil solution can be used under the advice of a medical doctor, but it is not available on NHS prescription and is expensive. Minoxidil solution should be applied to the affected scalp (not the hair) using a dropper or pump spray device and should be spread over the affected area lightly, it does not need to be massaged in. Minoxidil can cause skin reactions such as dryness, redness, scaling and/or itchiness at the site of application and should not be applied if there are cuts or open wounds. Minoxidil solution should only be applied to the scalp. Any spillage to the forehead or cheeks should be cleansed to avoid increased hair growth in these areas. Minoxidilshould be used for at least 6 months before any benefit may be noted. Any benefit will only be maintained for as long as the treatment is used.Minoxidil solution may cause an initial hair fall in the first 2-8 weeks of treatment, and this usually subsides when the new hairs start to grow.
  • Oral treatments such as spironolactone, cyproterone acetate, flutamide and cimetidine can block the action of dihydrotestosterone (a hormone)on the scalp, which may lead to some improvement in hair loss. These treatments are not licensed for use in FPHL. Spironolactone and cyproterone acetate should be avoided in pregnancy since they can cause feminisation of a male foetus; both should be avoided during breast feeding. Flutamide carries a risk of damaging the liver. It is important to note that all of these topical and oral treatments only work for as long as the treatment is continued. Wigs and hair pieces:
  • Some affected individuals find wigs, toupees and even hair extensions can be very helpful in disguising FPHL. There are two types of postiche (false hairpiece) available to individuals; these can be either synthetic or made from real hair. Generally, only synthetic wigs are available under the NHS. Synthetic wigs and hairpieces, usually last about 6 to 9 months, are easy to wash and maintain, but can be susceptible to heat damage and may be hot to wear. Real hair wigs or hairpieces can look more natural, can be styled with low heat and are cooler to wear.

Skin camouflage:

  • Spray preparations containing small pigmented fibres are available from the internet and may help to disguise the condition in some individuals. These preparations however, may wash away if the hair gets wet (i.e. rain, swimming, perspiration), and they only tend to last between brushing/shampooing.Surgical treatments:

Surgical treatment is not offered under the NHS. This can be sought privately. Hair transplantation is a procedure where hair follicles are taken from the back and sides of the scalp and transplanted onto the bald areas.

Abnormal-looking nails

The following are common nail abnormalities, with possible causes;

Transverse ridges are usually transient and due to a temporary disturbance of nail growth – eg, severe illness, trauma or infection. Beau’s lines occur in ALL nails, due a general cause preventing nail growth.

Other causes of transverse ridges include psoriasis, paronychia and eczema.

Causes include lichen planus, rheumatoid arthritis, myxoid cysts and peripheral arterial disease.

Causes include alopecia areata, psoriasis and eczema.

An increase in the soft tissue of the distal part of the fingers or toes; common causes of finger clubbing include:

  • Cyanotic congenital heart disease, infective endocarditis.
  • Lung cancer, pulmonary fibrosis, cystic fibrosis, bronchiectasis, empyema, lung abscess.
  • Dystrophy of the fingernails in which they are thinned and concave with raised edges (spoon-shaped nails).
  • May be due to iron deficiency or trauma.
  • A congenital nail disorder, autosomal dominant inheritance.
  • The patellae and some of the nails are rudimentary or absent.

These may be caused by pseudomonal infection, which results in green-blue or black dis-colouration.

May occur as a side-effect of certain medications, such as minocycline, hydroxyurea or mepacrine.

  • These may be a feature of Peutz-Jeghers syndrome, vitamin B12 deficiency, pseudomonas infection and post-irradiation.
  • Black streaks may indicate a junctional melanocytic naevus or malignant melanoma.
  • Purple/black dis-colouration occurs with a subungual haematoma. This should gradually grow distally and there is often (although not always) a history of trauma.

This may be congenital or due to minor trauma, hypoalbuminaemia in chronic liver disease, chronic kidney disease, Beau’s lines (as above, which may be white), fungal infection or lymphoma.

Yellow nail syndrome is characterized by slow-growing, excessively curved and thickened yellow nails which are associated with peripheral lymphoedema and exudative pleural effusions.

Causes include:

  • Nicotine staining from smoking (brown/yellow).
  • Trauma, particularly from poorly fitting footwear in active individuals, and particularly affecting the big toenail.
  • Dermatophyte or fungal infection.
  • Psoriasis.
  • Paronychia.

Medication including tetracyclines, captopril, trimethoprim, indometacin and isoniazid.

  • A common problem resulting from various causes – eg, improperly trimmed nails, trauma, poorly fitting shoes, abnormally shaped nails or pressure from other digits.
  • Also called onychocryptosis.
  • It often presents with pain but may progress to infection and difficulty with walking.
  • Treatment options include cutting nails square, hot water soaks, cotton wool inserts at the nail edges, antibiotics or excision and wedge excision or total excision of nail. A Cochrane review found that surgical treatments were more effective than non-surgical treatments.
  • The nail becomes detached from its bed at the base and side, creating a space under the nail that accumulates dirt. Air under the nail may cause a grey-white color but can vary from yellow to brown.
  • In psoriasis there may be a yellowish-brown margin between the margin between the normal nail (pink) and the detached parts (white).
  • If Pseudomonas aeruginosa grows underneath the nail then there may be a green color.
  • When nail bed separation begins in the middle of the nail then appearance resembles an ‘oil spot’ or ‘salmon patch’.
  • Causes of onycholysis include:
    • Idiopathic or inherited.
    • Systemic disease – eg, thyrotoxicosis.
    • Skin disease – eg, psoriasis.
    • Infection – eg, candida, dermatophytes, pseudomonas, herpes simplex.
    • Local causes – eg, trauma or chemicals.
  • Thickening and hardening of the nail plate, which becomes curved
  • Also called ram’s horn nails
  • Mainly seen on big toes of the elderly, associated with injury to the foot, badly fitting shoes or poor blood supply
  • Also called median canaliform dystrophy of Heller.
  • Small cracks in the centre of the nail extend laterally in the shape of the branches of a fir tree.
  • Also, the cuticle is pushed back and inflamed.
  • It usually affects one nail, and improves over time. The thumb is commonly involved.
  • Most commonly it results from the compulsive habit of a patient picking at a proximal nail fold thumb with an index fingernail.
  • Splinter haemorrhages are linear haemorrhages lying parallel to the long axis of fingernails or toenails.
  • They are red or brown/black.