Assessment of hair and alopecia
Normally, physiological hair distribution is divided into male and female types. The male type is characterized by the presence of long facial hair (mustache and beard growth), as well as coarser vellus hair on the trunk (chest and back) and extremities.
The pathological absence or noticeable thinning of hair in areas of its natural growth is called alopecia. Most commonly, this process is visualized on the scalp. Rapid hair loss can be triggered by a number of factors:
- Iatrogenic effects: use of anticoagulants, oral contraceptives, or prolonged cytostatic therapy for non-oncological diseases.
- Oncological treatment: active radiation therapy and the use of chemotherapy drugs.
- Endocrine disorders: thyroid pathologies (both hypothyroidism and hyperthyroidism), pituitary disorders (hypopituitarism), and adrenal cortex hyperplasia.
- Deficiency states: nutritional disorders, lack of essential micronutrients (primarily iron and zinc).
- Autoimmune and infectious processes: systemic lupus erythematosus (SLE), syphilis infection, or dermatomycosis.
- Psychogenic triggers: acute or chronic physical and psychological stresses.
Hirsutism: clinical presentation and causes
Hirsutism is pathologically excessive hair growth in women that follows a male pattern. Clinically, it manifests as the growth of a beard, mustache, as well as thick hair on the trunk and limbs. The pathogenesis is based on hyperandrogenemia, i.e., an excess of male sex hormones circulating in the blood.
The main causes of hirsutism include:
- Ovarian pathology: polycystic ovary syndrome (PCOS), ovarian dysfunction, and menopausal changes.
- Adrenal factors: androgen-secreting tumors (virilizing neoplasms).
- Iatrogenic causes: use of anabolic steroids, glucocorticoids, ACTH, cyclosporines, and progestogens (including as part of combined oral contraceptives).
The phenomenon of clubbing ("Hippocratic fingers")
The clubbing sign is detected by visual comparison of the patient's distal extremities with the healthy norm. Morphologically, it consists of two features:
- Drumstick sign: bulbous thickening of the soft tissues of the terminal phalanges of the hands.
- Watch-glass nail sign: alteration of the natural curvature of the nail plate, making it noticeably convex.
When identifying this phenomenon, it is important to exclude the hereditary form, which is not a sign of disease. Acquired clubbed fingers are associated with severe pathology of various systems:
- Respiratory system: chronic suppurative processes (bronchiectasis, lung abscess, pleural empyema), bronchogenic carcinoma, fibrosing alveolitis, and asbestosis.
- Cardiovascular system: cyanotic congenital heart defects, subacute infective endocarditis, subclavian artery aneurysm.
- Gastrointestinal tract and liver: liver cirrhosis, inflammatory bowel diseases (Crohn's disease, ulcerative colitis).
- Other: chronic hypoxia characteristic of living in high-altitude conditions.
Other pathological nail changes
During the examination, other specific changes in the nail plates may also be found that require differential diagnosis:
- Sideropenic syndrome: against the background of iron deficiency, the nails first flatten, and at an advanced stage acquire a spoon-shaped concavity (koilonychia).
- Trophic and fungal lesions: nail plates become coarse, thicken, break easily, and delaminate.
- Vascular and traumatic injuries: subungual hematoma can occur due to direct trauma to the distal phalanx. However, spontaneous appearance of subungual hematomas or areas of necrosis without prior mechanical impact often indicates capillaritis within the framework of systemic vasculitis.
To remember the main systemic causes of clubbed fingers, focus on the three main targets of hypoxia and inflammation: Lungs (suppuration, cancer), Heart (cyanotic defects, endocarditis), and Gastrointestinal Tract (cirrhosis, IBD).
Class and exam questions
What is the difference between clubbing and watch-glass nails?
Clubbing («drumstick fingers») describes the bulbous thickening of the soft tissues of the terminal phalanx itself, whereas nail curvature changes («watch-glass nails») pertain exclusively to the alteration in the shape of the nail plate, which becomes excessively convex.
How to differentiate a traumatic subungual hematoma from manifestations of vasculitis?
In systemic vasculitis (capillaritis), subungual hemorrhages and micronecrosis appear spontaneously. In trauma, there is always an anamnestically reported mechanical injury to the distal phalanx.
Which stage of iron deficiency does koilonychia indicate?
Koilonychia (spoon-shaped concavity of the nail) is a sign of an advanced stage of sideropenic syndrome. In the initial stages of iron deficiency, only flattening of the nail plate is observed.
Which medications most commonly cause the development of hirsutism?
Iatrogenic hirsutism can be caused by the intake of glucocorticoids, anabolic steroids, ACTH, cyclosporines, as well as progestogens included in oral contraceptives.
What else to study on this topic
- Pathogenesis of hyperandrogenemia in polycystic ovary syndrome (PCOS).
- Differential diagnosis of congenital and acquired cyanotic heart defects.
- Mechanisms of development of sideropenic syndrome and iron metabolism disorders.
- Clinical picture and diagnostic criteria for subacute infective endocarditis.
- Features of the differentiation of systemic lupus erythematosus and other autoimmune pathologies.
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