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A scalp biopsy is almost always for the evaluation of alopecia or balding.  A biopsy of nail may be to evaluate a chronic hyperkeratosis, fungal infection, or rarely to rule out a malignancy.  Dermatopathologists, experts in interpreting skin biopsies, usually interpret these biopsies.

The hair cycle begins in anagen, which lasts about 2-6 years with the average of about 1000 days. There is regional variation with faster cycles in the axilla and pubic region. The transition or catagen stage lasts for less than 2 weeks. Transforming growth factor-beta is expressed before catagen and tumor necrosis factor-beta is expressed during catagen. There is a reduction in bcl-2 expression allowing for apoptosis and hair involution. The resting phase is telogen and lasts for about 3-4 months. The telogen is followed by regrowth of the hair follicle and the anagen phase. The telogen hair or club hair is shed during this transition.

Dermatophyte (Tinea, Athlete's foot, Jock itch)


Laboratory/Radiologic/Other Diagnostic Testing  
Gross Appearance and Clinical Variants Hirsuitism
Hair Structural Abnormalities
Commonly Used Terms  
Internet Links  

Analysis of the expression pattern of glial cell line-derived neurotrophic factor, neurturin, their cognate receptors GFRalpha-1 and GFRalpha-2, and a common signal transduction element c-Ret in the human scalp skin.

Department of Zoology, Sohag Faculty of Science, South Valley University, Assir, KSA.


J Cutan Pathol. 2006 Dec;33(12):799-808. Abstract quote

Background: Glial cell line-derived neurotrophic factor (GDNF) and a related family member, neurturin (NTN), as well as their cognate receptors (GDNF receptors, GFRalpha-1 and GFRalpha-2, respectively) are involved in nervous system development and murine hair cycle control. To date, their expression in human scalp skin is still unknown.

Materials and methods: The expression pattern of these proteins was examined in human scalp skin by immunofluorescence and immunoalkaline phosphatase staining methods as well as RT-PCR (GDNF). A total of 50 normal human scalp skin biopsy specimens were examined (healthy females, 53-57 years).

Results: The expression of GDNF protein was strong in the epidermis and sebaceous and sweat glands. In the epidermis, GDNF protein expression was seen in all layers except the stratum corneum. It was strong in the basal layer and decreased gradually towards the granular layer. The results of RT-PCR analysis revealed that GDNF protein is synthesised in the epidermis. The expression of NTN, GFRalpha-1, and GFRalpha-2 proteins was strong in the papillary dermis and sebaceous and sweat glands. In the epidermis, NTN protein expression was absent. The expression of GFRalpha-1 and GFRalpha-2 proteins was moderate in the epidermis. The expression of c-Ret protein was consistently strong in the epidermis and sebaceous and sweat glands. These proteins were strongly expressed in both epithelial and mesenchymal compartments of human anagen VI scalp hair follicles.

Conclusions: Our investigation reports, for the first time, the expression patterns of GDNF, NTN, GFRalpha-1, GFRalpha-2, and c-Ret proteins in human scalp skin. The expression of these proteins in the skin suggests their possible roles in skin homeostasis. The clinical ramifications of these observations mandate further investigations.

The microanatomy of the distal arrector pili: possible role for a1b1 and a5b1 integrins in mediating cell-cell adhesion and anchorage to the extracellular matrix

Jeri Kersten Mendelson, Bruce R.Smoller, Bruce Mendelson and Thomas D. Horn

J Cutan Pathol 2000;27 (2), 61-66 Abstract quote

The arrector pili (AP) muscle is a small band of smooth muscle that attaches proximally to the bulge area of the pilosebaceous apparatus in the reticular dermis and extends up toward the epidermis. The distal anatomy of the AP and the anchorage mechanism allowing hair erection have not been previously described. Integrins are likely candidates mediating this attachment. Immunohistochemical techniques were used to determine the distribution of the following integrins: a1, a2, a3, a4, a5, a6 and b1 as well as fibronectin. Frozen human scalp tissue was sectioned in traditional planes, obliquely and horizontally to visualize microanatomy in three dimensions.

Histological examination revealed that the distal portions of smooth muscle fibers splay extensively between collagen bundles of the upper dermis. Integrin subunits a1, a5 and b1 were expressed by the AP muscle. Analysis of the relative density of immunoreactivity in digitized sections revealed increased a5 subunit expression at the extracellular matrix (ECM)-muscle interface. These data suggest that anchorage of the AP muscle to the ECM is via a5b1 integrin and a1b1 integrin functions in muscle cell-cell adhesion. Extensive splaying of smooth muscle fibers may allow increased surface area contact between the ECM and smooth muscle cells expressing peripherally situated a5 integrin.

Newly described weathering pattern in pili annulati hair shafts: A scanning electron microscopic study K. A. Feldmann, MD
R. P. R. Dawber, MA, FRCP
M. R. Pittelkow, MD
D. J. P. Ferguson, PhD, DSc

Oxford, United Kingdom, and Rochester, Minnesota

J Am Acad Dermatol 2001;45:625-7 Abstract quote

Certain scalp hair shafts from 2 of 10 cases of pili annulati examined by scanning electron microscopy exhibited an unusual weathering pattern. The majority of affected hair shafts showed minor surface abnormalities at regular intervals (nodes) associated with the underlying spaces. However, in a few examples, there was marked damage to the cuticle at the nodes exposing the underlying cortex; in severe cases there was cracking of both cuticle and cortex. These damaged nodes were also associated with trichorrhexis nodosa-like breaks of the hair shaft.

This study shows that the nodes in pili annulati may have some inherent weakness that could result in breaks in the hair shaft exposed to physical trauma.

Microtubule associated protein (MAP-2) expression defines the companion layer of the anagen hair follicle and an analogous zone in the nail unit.

Hallman JR, Fang D, Setaluri V, White WL.

Departments of Pathology and Dermatology, Wake Forest University School of Medicine, Winston-Salem, USA and Greensboro Pathology Associates, Greensboro, NC, USA.

J Cutan Pathol 2002 Oct;29(9):549-56 Abstract quote

BACKGROUND: Microtubule associated protein 2 (MAP-2) is one of a group of polypeptides that are an integral component of the microtubular cytoskeletal structure of the central and peripheral nervous system. During the course of another investigation that utilized immunohistochemistry, MAP-2 expression was observed in the hair follicle, almost exclusively in the innermost layer of the outer root sheath of the anagen follicle. This innermost layer, the so-called companion layer, has unique properties that clearly distinguish it from the rest of the outer root sheath. Among these are diminished glycogenation and an intimate association with the Henle's layer, which it directly apposes. Numerous intercellular connections exist between the companion layer and Henle's layer and, in fact, the companion layer accompanies Henle's layer during its vertical ascent in the follicle. Circumferentially oriented keratin filaments have also been demonstrated between the companion layer and Henle's layer, apparently providing structural support to the inner root sheath. Experimentally, disturbances in the keratin filaments of the companion layer in animals ultimately results in destruction of the hair follicle and an alopecia.

METHODS: Immunohistochemical studies for MAP-2 were performed on 25 additional paraffin-embedded scalp specimens using standard techniques. Because of the parallels between the follicle and nail, MAP-2 expression in the nail unit was also investigated in three specimens.

RESULTS: The presence of MAP-2 in the companion layer was confirmed in all cases. Intense MAP-2 expression in the companion layer begins at the B-fringe (the start of the keratogenous zone with cornification of the Henle's layer of the inner sheath) and extends to the level of the isthmus where the inner root sheath exfoliates. MAP-2 is also expressed in the upper layers of the nail matrix.

CONCLUSION: The expression of MAP-2 almost exclusively in the companion layer is probably related to the unique cytoskeletal structure of this microanatomic layer. Since experimental evidence has shown that the cell cytoskeleton is important to the integrity of the hair follicle, it is probable that MAP-2 expression is also important and disturbances in its expression could play a role in the pathogenesis of some alopecias. MAP-2 may play a similar role in the nail matrix.


Syndecan-1 is Strongly Expressed in the Anagen Hair Follicle Outer Root Sheath and in the Dermal Papilla but Expression Diminishes With Involution of the Hair Follicle.

Bayer-Garner IB, Sanderson RD, Smoller BR

Am J Dermatopathol 2002 Dec;24(6):484-9 Abstract quote

Syndecan-1 is the prototypic member of a family of heparan sulfate-bearing cell surface proteoglycans that function in adhesion, cell-extracellular matrix interactions, migration, and proliferation. During embryogenesis, syndecan-1 expression in the epithelium is downregulated when the epithelium gives rise to motile mesenchymal cells, whereas mesenchymal syndecan-1 expression is upregulated during organ formation. In aggressive basal cell carcinomas, syndecan-1 expression is evident in the stroma. Some neoplastic cells induce stroma to meet needs for growth, and it may be the mesenchymal cells that produce and shed syndecan-1 into the stroma.

The physiologic mechanism by which the hair follicle undergoes its cyclic process of involution and formation of a new active hair follicle is not well understood. Sixty scalp biopsies and a large scalp resection were evaluated for syndecan-1 expression within hair follicles in the growing (anagen), involuting (catagen), and resting (telogen) phases. Strong syndecan-1 immunoreactivity was evident in the outer root sheath (ORS) of the anagen hair follicle, but this expression diminished in intensity with the involution and resting stages in the hair follicle cycle.

The diminution of syndecan-1 immunoreactivity in the ORS of involuting and resting hair follicles may be a result of terminal keratinocyte differentiation. Syndecan-1 was also present in the dermal papilla of the anagen hair follicle, where it may promote growth factor-mediated cell signaling that induces and maintains growth of the hair shaft and the inner root sheath.


Excessive hair growth may be a manifestation of several internal medical diseases or may be a drug side effect.



Wendelin DS, Pope DN, Mallory SB.

St Louis Children's Hospital

J Am Acad Dermatol 2003 Feb;48(2):161-79 Abstract quote

Hypertrichosis is hair growth that is abnormal for the age, sex, or race of an individual, or for a particular area of the body.

Recognized forms of hypertrichosis are reviewed. Hirsutism, which is male-pattern hair growth in a female or child, is not included in this review. Hypertrichosis is categorized as congenital or acquired, and regional or generalized. Methods of managing hypertrichosis are also briefly reviewed. (J Am Acad Dermatol 2003;48:161-79.)

Learning objective: At the completion of this activity, participants should be familiar with the causes of hypertrichosis and treatment modalities.

Facial and abdominal hair growth in hirsutism: A computerized evaluation

Gene Hinesa
Carlos Morana
Raquel Huertaa
Kelli Folgmana
Ricardo Azziza,

Birmingham, Alabama

J Am Acad Dermatol 2001;45:846-50. Abstract quote

Methods of objectively assessing the growth rate of hairs in hirsute women have generally required some form of shaving and have focused on studying hairs affecting the face, which has reduced the number of patients willing or able to participate in such studies. A possible solution is to assess the terminal hairs on the lower abdomen (ie, the male escutcheon) because these two body areas are the most frequently affected with excess hair growth in hirsute patients. Nonetheless, it is unclear how the growth characteristics (density, diameter, and growth rate) of the hairs on the abdomen and face differ in these patients. We hypothesize that the growth characteristics of terminal hairs on the abdomen and face are similar and that evaluation of either area may be sufficient in assessing the hair growth rate of these patients.

To objectively evaluate hair growth in the face and abdomen in hirsute patients, we developed a computer-aided image analysis system capable of measuring several growth parameters. Twenty hirsute women (12 white and 8 black), aged 31.2 ▒ 6.1 years, were studied. Facial and abdominal skin areas were shaved, and 3 to 5 days later the areas were photographed through a calibrated glass plate and 5 terminal hairs were plucked from each area. The daily hair growth rate (assessed by photography and by direct measurement of the plucked hair), the density of hairs (number of hairs per surface area assessed by photography), and hair diameter (of the plucked hairs) were determined. The extent of hirsutism was also measured, albeit subjectively, by a modification of the Ferriman-Gallwey method, with each area given a score of 0 (no terminal hairs seen) to 4 (terminal hairs in a pattern similar to that of a very hirsute man). Facial, abdominal, and total Ferriman-Gallwey scores were 1.3 ▒ 0.6, 1.8 ▒ 0.9, and 12.5 ▒ 5.4, respectively.

Our results indicated that facial hairs were distributed in greater density and had a greater diameter than abdominal hairs (15.6 ▒ 14.2 hairs/cm2 vs 5.4 ▒ 1.9 hairs/cm2, and 84.5 ▒ 19.5 Ám and 66.2 ▒ 17.5 Ám, respectively, P < .005). Alternatively, the growth rates of facial and abdominal hairs were similar, whether determined photographically (0.36 ▒ 0.18 mm/day vs 0.43 ▒ 0.19 mm/day, respectively) or from plucked hairs (1.2 ▒ +0.2 mm/d vs 1.4 + 0.4 mm/d, respectively). We conclude that although the density and diameter of facial hairs are greater than that of lower abdominal hairs, these areas have very similar growth rates.

Hence evaluation of either of the body areas, using an objective method of assessing hair growth, should provide equivalent results.

Hair-Structural Abnormalities


Is the loose anagen hair syndrome a keratin disorder?: a clinical and molecular study.

Chapalain V, Winter H, Langbein L, Le Roy JM, Labreze C, Nikolic M, Schweizer J, Taieb A.

Service de Dermatologie, Hopital St Andre, 1 rue Jean Burguet, 33075 Bordeaux CEDEX, France.

Arch Dermatol 2002 Apr;138(4):501-6 Abstract quote

OBJECTIVES: To report the clinical features of the loose anagen hair syndrome and to test the hypothesis that the typical gap between the hair and the inner root sheath may result from hereditary defects in the inner root sheath or the apposed companion layer.

DESIGN: Case series.

SETTING: A pediatric dermatology unit (referral center).

PATIENTS: A consecutive sample of 17 children (13 girls). For 9 of them and their first-degree relatives, molecular analyses were performed in the K6HF gene with 50 appropriate controls.

INTERVENTION: Minoxidil therapy (5% lotion) in 11 patients for 1 to 12 months.

MAIN OUTCOME MEASURES: Clinical and follow-up features and determination of mutations in the K6HF gene.

RESULTS: Most patients had easily pluckable hair with no sign of scalp inflammation or scarring. Ten patients seldom cut their hair, and 4 had unmanageable hair. One patient had hypodontia. Two patients had an additional clinical phenotype of diffuse partial woolly hair. The family history was positive for loose anagen hair syndrome in 5 patients. Marked improvement was noted after treatment with 5% minoxidil lotion in 7 of the 11 patients treated. Polymerase chain reaction analysis of the gene segments encoding the alpha-helical 1A and 2B subdomains of K6hf, the type II cytokeratin exclusively expressed in the companion layer, was performed in 9 families. In 3 of these 9 families, a heterozygous glutamic acid and lysine mutation, E337K, was identified in the L2 linker region of K6HF.

CONCLUSIONS: Diffuse partial woolly hair can be associated with loose anagen hair syndrome. A keratin mutation, E337K in K6HF, was possibly causative in 3 of the 9 families studied. Another keratin, and possibly the type I partner of K6hf, could be responsible for loose anagen hair syndrome in other patients, or the gene involved may be a minor gene.


Three members of a family with pili torti and sensorineural hearing loss: The Bjornstad syndrome

Kristen A. Richards, MD
Anthony J. Mancini, MD

Chicago, Illinois

J Am Acad Dermatol 2002;46:301-3 Abstract quote

Thirty cases of the Bjornstad syndrome (sensorineural deafness and pili torti) have been reported between 1965, when it was first described, and 1999. Both autosomal dominant and recessive inheritance patterns appear in the literature.

We describe a family in which 3 members have the combination of pili torti and varying degrees of hearing loss inherited in an apparently autosomal dominant fashion. Hairs from the father and son of this family showed the classic features of pili torti under scanning electron microscopy.

Virus-Associated Trichodysplasia Spinulosa.

Wyatt AJ, Sachs DL, Shia J, Delgado R, Busam KJ.

From the *Department of Dermatology, New York Presbyterian Hospital, Weill Medical College of Cornell University; daggerDermatology Service, Department of Medicine, and double daggerDepartment of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY.
Am J Surg Pathol. 2005 Feb;29(2):241-246. Abstract quote

Virus-associated trichodysplasia spinulosa (VATS) is a cutaneous eruption of spiny papules predominantly affecting the face that is associated with a distinctive histologic picture of abnormally maturing anagen follicles with excessive inner root sheath differentiation and hyperkeratotic infundibula. Ultrastructurally, intranuclear viral particles consistent with polyoma virus are found. Only 2 patients have thus far been reported. Both had developed the eruption after a kidney transplant.

We report 2 additional cases of VATS. One is an 8-year-old boy who presented with facial papules after a kidney transplant. The other is a 19-year-old man with a history of acute lymphocytic leukemia who never had a transplant. He developed a papular facial eruption as well as alopecia. Light microscopic and ultrastructural examinations revealed a spectrum in the severity of the histologic alterations as well as the number of intranuclear viral particles. This report expands the range of pathologic alterations associated with VATS and documents for the first time that it can affect patients without a solid organ transplant.

The similarity of the clinical and histologic features of VATS with those previously reported by others as cyclosporine-induced "follicular dystrophy" or "pilomatrix dysplasia" raises the possibility that the described phenomena may reflect the same entity. Increased awareness of the distinct histologic picture associated with VATS will likely lead to more frequent diagnosis of this underrecognized entity.
Characterization of tiger tail banding and hair shaft abnormalities in trichothiodystrophy.

Liang C, Kraemer KH, Morris A, Schiffmann R, Price VH, Menefee E, DiGiovanna JJ.

DNA Repair Section, National Cancer Institute, Bethesda, Maryland, USA.
J Am Acad Dermatol. 2005 Feb;52(2):224-32. Abstract quote

BACKGROUND: Tiger tail banding under polarizing light microscopy and hair shaft abnormalities are associated with trichothiodystrophy (TTD), a rare disorder with a wide spectrum of clinical presentations.

OBJECTIVE: To characterize the frequency, specificity, and extent of tiger tail banding and hair shaft abnormalities in the spectrum of TTD patients.

METHODS: We developed a standardized procedure for microscopic hair examination and studied hairs from 14 TTD and 4 xeroderma pigmentosum (XP)-TTD patients for tiger tail banding and hair shaft abnormalities. For comparison we examined hairs from 173 control donors consisting of 15 normals, 13 XP patients, 11 family members of XP or TTD patients, 101 patients with various cornification disorders, and 33 leukodystrophy patients. Amino acid analysis performed on hair from the TTD and XP-TTD patients showed low sulfur content.

RESULTS: Using a rotating microscope stage, all hairs in each TTD sample showed tiger tail banding under polarized light in association with a variety of hair shaft abnormalities (trichoschisis, trichorrhexis nodosa-like defects, surface irregularities, and ribboning). None of the control hairs showed tiger tail banding, and 5 of 173 controls had weathering hair shaft abnormalities.

CONCLUSIONS: In patients with clinical features suggestive of TTD, tiger tail banding seen in all hairs with polarizing microscopy, in conjunction with certain hair shaft abnormalities, provides a reliable diagnostic test.

"Curly" wood and tiger tails: an explanation for light and dark banding with polarization in trichothiodystrophy.

Sperling LC, DiGiovanna JJ.

Department of Dermatology, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20854, USA.
Arch Dermatol. 2003 Sep;139(9):1189-92. Abstract quote  

The mechanism causing the tiger tail phenomenon in trichothiodystrophy (alternating light and dark banding of hair shafts when examined with polarized light) has yet to be explained with certainty. However, we propose a simple and easily tested hypothesis to explain its striking aspect. Although the hair shafts we obtained from patients with trichothiodystrophy were fairly straight, the cortical hair fibers were not.

We noticed that these fibers undulate up and down (or back and forth), a feature that is easily observed because of melanin granules embedded in each fiber. The undulations correspond exactly to the banding seen with polarization. Therefore, the tiger tail phenomenon seen in trichothiodystrophy and other hair shaft disorders is caused by a regular undulation of hair fibers within the shafts. Normal hair shafts do not exhibit the phenomenon because the hair fibers are straight and parallel to the long axis of the hair.

It is the regular undulation of fibers that changes the optical properties of the hair shafts and causes a predictable banding when the shafts are examined by polarized light.

Itraconazole therapy for white piedra affecting scalp hair.

Khandpur S, Reddy BS.

Department of Dermatology and S.T.D., Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi.

J Am Acad Dermatol 2002 Sep;47(3):415-8 Abstract quote

BACKGROUND: Treatment of white piedra remains an area of therapeutic frustration. Several topical and systemic antifungal agents have failed to eradicate the fungus and prevent disease recurrence. Itraconazole is a safe and effective systemic antifungal agent for various superficial and deep mycotic infections of the skin and hair. In vitro studies have shown significant antifungal activity against Trichosporon beigelii.

OBJECTIVE: Our study was intended to assess the efficacy of itraconazole in the treatment of uncomplicated white piedra affecting the scalp hair.

METHODS: The study was designed as an open trial involving 12 female patients with white piedra of the scalp hair. They were administered oral itraconazole 100 mg once daily until culture negativity was achieved; they were then followed up for 3 months.

RESULTS: Eleven patients (91.67%) showed disease remission after 8 weeks of treatment. One patient (8.33%) showed no improvement, and the disease recurred in 2 patients (16.67%) after completion of therapy. No significant side effects were noted.



There are many systemic diseases which may be gleaned with examination of the nail. A short differential diagnostic list is presented below.

Blue discoloration of lunulae
Yellow Nail Syndrome
  Am J Med Genet 2000;93:1-4
Pregnancies of women with this syndrome may be complicated by fetal hydrops
ROUGH, THINNED NAILS Twenty nail dystrophy (TND)-Trachyonychia
ONYCHOLYSIS Systemic chemotherapy
  Br J Dermatol 2000;143:462-463
Docetaxel and Paclitaxel
ONYCHOTILLOMANIA Biol Psych 2000;48:287-293
Anorexia nervosa and bulimia
Melanotic macule of nail unit and its clinicopathologic spectrum.

Husain S, Scher RK, Silvers DN, Ackerman AB.

College of Physicians and Surgeons, Columbia University, New York, New York, USA.
J Am Acad Dermatol. 2006 Apr;54(4):664-7. Abstract quote  

The clinical and histologic spectrum of melanotic macule of the nail unit is examined and the differences in the clinical appearance of longitudinal melanochychia caused by melanotic macule and by other kinds of proliferations of melanocytes are assessed.

We observed that the clinical appearance of the pigmented band was of little help in establishing the underlying basic pathologic process.

This underscores the importance of obtaining a biopsy of the nail matrix in patients who present with solitary longitudinal melanonychia.
Longitudinal melanonychia of the toenails with presence of Medlar bodies on biopsy.

Ko CJ, Sarantopoulos GP, Pai G, Binder SW.

Department of Pathology and Laboratory Medicine, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA.

J Cutan Pathol. 2005 Jan;32(1):63-5. Abstract quote  

A 9-year-old girl presented with a 2-year history of pigmented streaks on her second right toenail as well as on her fourth and fifth left toenails. The patient was otherwise asymptomatic with no other physical findings.

Owing to parental concern, a biopsy was performed, which revealed numerous bacteria as well as Medlar bodies overlying the nail bed with no evidence of a nevomelanocytic lesion.

To our knowledge, this is the first report of Medlar bodies causing pigmented streaks in the toenails.
Muehrcke's lines

Arch Intern Med 1965;116:875-8.

Double white transverse bands with a contour parallel to the proximal nailfold, occur in chronic hypoalbuminemia because of abnormal nail bed vascularity

Application of pressure to the distal digits results in momentary disappearance of the lines, which do not affect the nail plate



A psychometric study of patients with nail dystrophies

Murad Alam, MDa
Meena Moossavi, MD
Iona Ginsburg, MD
Richard K. Scher, MD

New York, New York

J Am Acad Dermatol 2001;45:851-6. Abstract quote

Background: Survey studies suggest that patients with various dermatologic conditions experience concomitant psychologic distress.

Objective: The purpose of this study was to determine which types of psychologic distress may be correlated with dystrophic disease of the nail in nonpsychiatric patients.

Methods: Fifty-seven adult subjects presenting for treatment of nail dystrophies completed a survey instrument, which included 5 psychometric measures.

Results: On average, patients rated the severity of their nail dystrophy and functional deficit higher (7.40/10 and 6.00, respectively) than investigators (6.15 and 3.75, respectively). Compared with age- and sex-matched nonpsychiatric patients, subjects in the study were moderately more anxious and minimally to mildly more depressed. Subjects had moderately depressed total self-concept, but their body image was approximately normal. Overall, subjects exhibited markedly more severe psychologic symptoms (84th percentile) than the normal sample, with the scores on the psychoticism, obsessive-compulsive, and paranoid ideation subscales being the most elevated.

Conclusion: The subjects with nail dystrophy had markedly exacerbated psychologic symptoms compared with age- and sex-matched nonpsychiatric patients.


Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study.

Tosti A, Piraccini BM, Ghetti E, Colombo MD.

Department of Dermatology, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy.

J Am Acad Dermatol 2002 Jul;47(1):73-6 Abstract quote

BACKGROUND: The involvement of Candida in the pathogenesis of chronic paronychia (CP) has never been proven, even though this condition is commonly considered a type of Candida onychomycosis.

OBJECTIVE: The purpose of this study was to compare the efficacy of systemic antifungals (itraconazole or terbinafine) with a topical corticosteroid (methylprednisolone aceponate) in the treatment of patients with CP.

METHODS: The study involved 45 adult patients with CP. Medication was given in a randomized, double-blind and double dummy manner over 3 weeks. Patients were then followed for 6 weeks. Clinical and mycologic evaluations were performed at baseline, and at weeks 3 and 9. The efficacy measures included clinical and photographic evaluation.

RESULTS: Of 48 nails treated with methylprednisolone aceponate, 41 were improved or cured at the end of the follow-up period. The statistical analysis showed a significant difference between the number of nails improved or cured by methylprednisolone aceponate and that of nails improved or cured with terbinafine (30 out of 57) or itraconazole (29 out of 64). Presence of Candida was not strictly linked to disease activity, and Candida eradication was associated with clinical cure in only 2 of the 18 patients who carried Candida at the beginning of the study.

CONCLUSION: This study shows that topical steroids are more effective than systemic antifungals in the treatment of CP, and supports the view that CP is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure.

Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance.

Spicknall KE, Zirwas MJ, English JC 3rd.

Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

J Am Acad Dermatol. 2005 Jun;52(6):1020-8. Abstract quote  

Finger clubbing can be a striking physical finding. At other times, the presence of clubbing is difficult to establish by subjective examination alone and the profile angle or distal phalangeal to interphalangeal depth ratio are needed to confirm the finding.

Most microscopic and imaging studies of clubbed fingers reveal hypervascularization of the distal digits. Recent research shows that when platelet precursors fail to become fragmented into platelets within the pulmonary circulation, they are easily trapped in the peripheral vasculature, releasing platelet-derived growth factor and vascular endothelial growth factor, promoters of vascularity and, ultimately, clubbing.

Clinically, clubbing is associated with a number of neoplastic, pulmonary, cardiac, gastrointestinal, infectious, endocrine, psychiatric, and multisystem diseases. In narrowing the differential diagnosis, we recommend a detailed history and physical examination accompanied by focused laboratory and imaging studies.

An algorithm for the evaluation of newly diagnosed clubbing is suggested.
A morphological study of ectopic plantar nail.

Mazzarello V, Ena P, Dessy LA.

Department of Biomedical Sciences, University of Sassari, Sassari, Italy.
Am J Dermatopathol. 2005 Apr;27(2):122-5. Abstract quote  

Ectopic nails are rare. Four adult patients presented to us, affected by true ectopic nails of the foot, sole, and toes, occurring bilaterally in one case. Full documentation of these anomalies was collected.

The aim of this study was to better describe the morphologic features of ectopic plantar nails by using, besides histologic evaluation, transmission and scanning electron microscopy. New morphologic criteria were identified to determine if ectopic plantar nail differed from normal and ectopic hand nails.

Morphologically, ectopic plantar nails are smaller than normal ones, but still form cuticles, nail grooves and nail folds, and periungual wrinkles. Furthermore, they form with a flat angle between the nail matrix and proximal nail fold, and have a nail plate interrupted by several transverse nails grooves.

Nail disorders in hemodialysis patients and renal transplant recipients: A case-control study.

Saray Y, Seckin D, Gulec AT, Akgun S, Haberal M.

J Am Acad Dermatol. 2004 Feb;50(2):197-202. Abstract quote  

BACKGROUND: There is one published case-control study of nail disorders in hemodialysis patients. The nail changes that occur in renal transplant recipients have not been investigated specifically.

OBJECTIVE: The aim of this study was to determine prevalence rates of nail disorders in hemodialysis patients and renal transplant recipients, and to investigate whether these nail pathologies are related to hemodialysis and renal transplantation.

METHODS: One hundred and eighty-two hemodialysis patients and 205 renal transplant recipients were screened for the presence of nail disorders. The findings in these groups were compared with findings in 143 healthy individuals.

RESULTS: One hundred and twenty-seven patients (69.8%) in the hemodialysis group and 116 patients (56.6%) in the renal transplant recipients had at least one type of nail pathology. Absence of lunula, splinter hemorrhage, and half-and-half nails were significantly more common in the hemodialysis patients than in the renal transplant recipients. Leukonychia was significantly more frequent in the renal transplant recipients than in the hemodialysis patients and controls.

CONCLUSION: Hemodialysis patients and renal transplant recipients have higher rates of nail disease than the healthy population. Renal transplantation may reduce the frequencies of splinter hemorrhage and half-and-half nails. Interestingly, leukonychia increases significantly after renal transplantation.



Dermoscopic examination of nail pigmentation.

Ronger S, Touzet S, Ligeron C, Balme B, Viallard AM, Barrut D, Colin C, Thomas L.

Dermatology Unit, Hotel Dieu de Lyon, 69288 Lyon CEDEX 02, France.

Arch Dermatol 2002 Oct;138(10):1327-33 Abstract quote

BACKGROUND: Diagnosis of longitudinal melanonychia is usually difficult, and neither a single clinical criterion nor a combination of symptoms currently can be used to clearly distinguish malignant from benign bandlike pigmented nail lesions. Biopsy is painful and often leaves definitive dystrophic scars.

OBJECTIVES: To describe and evaluate dermoscopic patterns associated with longitudinal nail pigmentation.

PATIENTS AND METHODS: A total of 148 unselected consecutive cases of longitudinal melanonychia were included over a period of 4 years (20 melanoma, 37 nevi, 16 drug-induced nail pigmentation, 45 nail apparatus lentigo of various types, 8 ethnic-type nail pigmentation, and 22 subungual hemorrhages). All patients were recruited from the dermatology unit outpatient clinic of the Hotel Dieu de Lyon. All cases were photographed in vivo under oil immersion (dermoscopy). Patterns were recorded prior to final pathologic diagnosis. An independent biostatistics unit performed statistical evaluation using 7 semiologic patterns.

RESULTS: Melanoma cases were significantly associated with a brown coloration of the background and the presence of irregular longitudinal lines (P =.001). Blood spots were mostly observed in subungual hemorrhages (P =.001); however, their presence could not rule out melanoma. Micro-Hutchinson sign was observed only in melanoma, but its rare occurrence did not allow any statistical evaluation of its specificity. Nail apparatus nevi were significantly associated with a brown coloration of the background and the presence of regular lines (P =.001). Nail apparatus lentigo, ethnic-type pigmentation, and drug-induced pigmentation were significantly associated with homogeneous longitudinal thin gray lines and gray coloration of the background (P =.001). Microscopic longitudinal grooves were unspecific, occurred in several conditions, and were associated with any type of ungual discoloration.

CONCLUSIONS: We believe that dermoscopic examination of the nail plate in cases of longitudinal melanonychia provides useful information that could help clinicians to more accurately decide if a nail apparatus biopsy should be performed; however, histopathologic diagnosis remains the gold standard in doubtful cases.

Adapted from Algorithms for Histologic Diagnosis of Inflammatory Skin Diseases. Second Edition. Williams and Wilkins. 1997.
Macpherson and Pincus
. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

CCommonly Used Terms With Diseases of the Hair

Anagen-Growth phase of new hair, normal conditions have 85-90% of hair follicles in this stage.

Catagen-Terminal stage of hair growth, normal conditions have less than 1% of hair follicles in this stage.

Telogen-Resting phase of hair growth, normal conditions have 10-15% of hair follicles in this stage.

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