#232 Skinternship: Scalp & Face

September 14, 2020 | By Beth Garbitelli

Dermatology tips and tricks for hair loss, scalp flakes, facial rashes, and acne with Dr. Helena Pasieka MD

Dive deep into common dermatological conditions of the scalp and face including alopecia, seborrheic dermatitis, rosacea, acne, and even the scourge of health professionals, ‘maskne’! We are joined by our Kashlak Chief of Dermatology and resident Skinternist Dr. Helena Pasieka (of @MedStarWHC). After listening to this episode, your dermatology knowledge will be head and shoulders above the rest!

Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).

Note: The full slide deck with images for this episode is not available at this time. We will post it to this show notes page as soon as we clear the image rights.

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Credits

• Written and Produced by: Beth Garbitelli, Matthew Watto MD, FACP, 
• Cover Art and Infographic by:  Beth Garbitelli
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP, Beth Garbitelli  
• Editor:  Cyrus Askin MD (written materials); Clair Morgan of nodderly.com
• Guest: Helena Pasieka MD, MS

Sponsor

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VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

How to Claim VCU CME Credit

Time Stamps

• Sponsor – Provider Solutions & Development www.psdrecruit.org/curbsiders.
• Sponsor – VCU Health Continuing Education
• 00:30 Intro, disclaimer, guest bio
• 04:35 Guest one-liner, Picks of the Week*: Hamilton and Alexander Hamilton by Ron Chernow, Ultra-Gooey Stovetop Mac and Cheese Recipe, The Food Lab: Better Home Cooking Through Science by J. Kenji Lopez-Alt
• Sponsor – Provider Solutions & Development www.psdrecruit.org/curbsiders
• 08:30 Case 1: Alopecia 
• 12:05 Assessing scalp for inflammatory changes and follicular drop-out
• 13:10 Central Centrifugal Cicatricial Alopecia (CCCA)
• 14:00 Alopecia/hair loss non-scarring subtypes
• 25:00 Alopecia Treatments
• 28:55 Case 2:  Psoriasis vs. Seborrheic Dermatitis 
• 31:45 Looking for psoriatic plaques
• 32:11 Seborrheic dermatitis hallmarks 
• 35:19 Treatment for Seborrheic Dermatitis
• 42:10 Case 3: Rosacea vs. Acne 
• 50:40 Differentiating rosacea rash from SLE
• 52:40 Rosacea management & treatment
• 55:00 Identifying rosacea in Black skin
• 56:50 Acne management &  treatment
• 59:10 Retinoid dermatitis
• 1:00:30 Maskne
• 1:02:29 Antibiotics for acne
• 1:03:38 Retinoids and pregnancy
• 1:04:09 Doxycycline for rosacea
• 1:06:15 Take home points
• Sponsor – VCU Health Continuing Education

“Derm is Medicine” -Dr. Helena Pasieka

Skinternship: Scalp and Face Pearls

1. Hair loss of 50 – 200 hairs per day is normal (Dr. Pasieka).
2.  Index of suspicion is higher for scarring hair loss in patients with deeper skin tones with textured hair types. Black women are at risk for a condition known as Central Centrifugal Cicatricial Alopecia (CCCA) (Aguh, JAMA 2020).  
3. Bulky lymphadenopathy frequently accompanies a fungal etiology for hair loss. Boggy texture at bald spots also associated with fungi (Fuller, BMJ 2003).
4. New and impressive onset of seborrheic dermatitis may indicate HIV (Chatzikokkinou, Acta Dermatovenerol Croat. 2008). 
5. Seborrheic dermatitis may also flare after neurological injury (Han, J Spinal Cord Med 2015). 
6. Inquire from patients about how they style their hair and how frequently they wash their hair to assess the best delivery model for ketoconazole medication (expert opinion).
7.  If you visualize open comedones (a.k.a.: blackheads), you are probably seeing acne, not rosacea (Gold, J. Cosmet. Dermatol. 2018). 
8. Train eye to assess post-inflammatory pigmentation changes and keloid formation in patients with darker skin tones (expert opinion). 
9. When trying to assess Erythematotelangiectatic (ETT) rosacea versus SLE, look at the hands. Hands receive tons of photo exposure and frequently have a photosensitive rash that spares the knuckles in SLE. SLE patients may have ulcers in their mouth as well (expert opinion).
10. Advise sensitive, gentle skin care and mineral (zinc or titanium) sunscreen for all patients with rosacea and acne (Zip, Skin Therapy Lett. 2017). 

Skinternship PGY1 – Show Notes

Case 1 – Female with stress, hair loss, and a bag of hair 

Dr. Pasieka notes that hair loss of 50-200 hairs a day is totally normal.  She recommends assessing other ‘hair-bearing sites’ of the face and body when a patient complains of hair loss, including eyelashes, eyebrows, and facial hair.  Axillary and pubic hair regions can also provide information.  A visual assessment of the scalp in its entirety will be helpful to both assess the skin changes of the hair loss regions, the pattern of hair loss, and the follicular impact. Widening of the part may be seen in some patients and is a good place to start (expert opinion). 

To Scar or Not To Scar

When evaluating a patient with concern for hair loss, it is important to differentiate between scarring (permanent)  or non-scarring (regrowth potential) alopecia.  Index of suspicion is higher for scarring hair loss in patients with deeper skin tones with textured hair types. Black women are at risk for a condition known as Central Centrifugal Cicatricial Alopecia (CCCA) —Aguh, JAMA 2020.  CCCA is a  scarring type of alopecia and is related to an inflammatory process that  destroys hair follicles. Dr. Pasieka advises that in these patients “time is hair” and an immediate referral to dermatology should be made. 

To assess scarring hair loss, Dr. Pasieka suggests that the provider considers whether there is a follicular ostia (follicular hole) everywhere you’d expect to see one? She also recommends that skin shine, skin color,  scaling and sensation (itching, burning, tingling) should all be assessed. 

Kashlak Pearl:  Bulky lymphadenopathy frequently accompanies a fungal etiology for hair loss. Boggy texture at bald spots also associated with fungi (Fuller, BMJ 2003) 

Hair Loss Subtypes

Androgenic Alopecia (a.k.a: Male-Pattern Hair Loss)

Key Characteristics: This subtype may feature a widening central part. Bald spots will be shiny due to upregulation of sebaceous glands. Hair calibers will be varying diameters.  Approximately 80% of caucasian men will have androgenic alopecia by age 70 (Stough, Mayo Clinic Proceedings 2005) and many women also experience this type of hair loss. 

Treatment: Mainstay is topical minoxidil. Dr. Pasieka advises her female patients to use the formula made for men, as it has a higher percent active ingredient.  Generally, it should be used nightly for 16 weeks to determine if it is efficacious. Using minoxidil will cause paradoxical shedding of hair so patients should be counseled to expect this temporary side effect.  Additionally, this is a therapy that would be used indefinitely. Dermatology consult could assist with systemic therapy (such as finasteride) for patients that are very troubled. 

Telogen effluvium (a.k.a: Stress Shedding) 

Key Characteristics: All hair calibers will be the same diameter and patients may note a decreased ponytail caliber per Dr. Pasieka. Why does this occur? This can be thought of as a physical manifestation of stress whereby an individual experiences some sort of stress (physical, psychological, emotional) which results in hair loss. As their body is “focusing” on dealing with the stress, hair loss may result. Specific examples include pregnancy or metabolic change which may  alter an individual’s biological clock resulting in a period of accelerated hair loss  (Asghar, Cureus 2020). 

Treatment: Minoxidil may be offered. Although impact is unclear, it may help patients feel proactive (expert opinion). 

Alopecia Areata 

Key Characteristics: Completely smooth, well-defined spot on scalp. It will generally be non-erythematous and non-scarring. Follicular ostia will be present.  Autoimmune process causing the hair loss will also knock out the melanin, so hair growth may be silvery-white. Nail pitting may also be present (Gilhar, NEJM 2012). This type can become disseminated (diffuse) so Dr. Pasieka recommends referral to dermatology.

Treatment: Topical steroids as a stop-gap while awaiting formal dermatologic evaluation.

Lab Workup For Hair Loss

Dr. Pasieka advises a limited work-up. Helpful labs include thyroid function, chem panel, ESR, hematocrit, ferritin and vitamin D levels. Do not order Antinuclear Antibody unless there are other clear symptoms.  Lore from literature finds that ferritin greater than 70 ng per milliliter may be beneficial for hair growth (Shapiro, NEJM 2007) and vitamin D may require supplementation if very low, although both of these guidelines may lack strong evidence (Shapiro, NEJM 2007).

Case 2 – The Greasy Scalp: Location, location, location

When assessing a flaking or greasy scalp complaint, you will need to assess the entire body for other potential patches. 

Psoriasis 

Psoriasis can involve elbows, knees, gluteal cleft, and belly button (Armstrong, JAMA 2020). These sites will feature erythematous plaques with micaceous flake/plaque. Skin will be less ‘oily’ in psoriasis than with seborrheic dermatitis, per Dr. Pasieka. 

Treatment: Psoriasis tends to present as a systemic disease. Patients will sometimes present with arthritis, which tends to be asymmetric, oligoarthritis, and involving the small joints of hands and feet, per Dr. Pasieka. Psoriasis is also associated with depression, metabolic syndrome, and cardiovascular risk (Armstrong, JAMA 2020). Mild patches without other systemic symptoms can be treated in primary care with moderate corticosteroids, but if they have other symptoms, especially psoriatic arthritis, they should be managed by dermatology and rheumatology. 

Seborrheic Dermatitis 

Seborrheic dermatitis features a greasy, waxy scale and has a predilection for areas that are rich in sebaceous glands including, scalp, face, nasolabial zone, ears,  and sternal area.  It is caused by lipophilic yeasts and will not generally be found in the extensor pattern for psoriasis.  If they’ve never had seborrheic dermatitis before and it’s an impressive onset, it may be a cutaneous sign of HIV (WHO 2014). It also tends to flare after neurological injury (Han, J Spinal Cord Med 2015). 

Treatment: Ketoconazole shampoo can be used for scalp and as a body wash for affected skin. This regimen may be combined with ketoconazole cream 2 times a day.  For textured hair types, shampoos may not be the best route as they can be extremely drying. Inquire from patients about how they style their hair and how frequently they wash their hair to assess the best delivery model for the ketoconazole medication.  Fluocinolone ointment (a high potency steroid) may be used sparingly as can less potent steroid preparations.

Case 3 – Rosy Cheeks, Butterfly Rashes & … Zits

Central face rash after sun exposure can lead you to think of lupus but the most common culprits would be acne or rosacea. Acne mimics papulopustular rosacea.

Acne

Key Characteristics: Age range is important. Acne can start as young as school age but can persist well into adulthood. It’s a disease of the pilosebaceous unit involving follicular hyperkeratinization, hormonal influence on sebum, and inflammation mediated by bacteria p.acnes/c.acnes (Zaenglein, NEJM 2018).  Look for distribution on oil-producing areas including back/chest and assess keloid formation in darker skin tones, per Dr. Pasieka.  Variation with menstrual cycle is a component of hormonal acne and this type presents on the jawline and near mouth. Icepick/boxcar scarring is present in acne and not rosacea, per Dr. Pasieka.  Acne is undertreated in Black patients (Barbieri, JAMA 2020)

Kashlak Pearl: If you visualize open comedones (a.k.a. blackheads), you are probably seeing acne, not rosacea. 

Treatment:  The patient should assess all products they use and make sure they are all non-comedogenic.  Mainstay of treatment are topical retinoids, including OTC adapalene.  Patients should apply a pea-sized amount for the entire face, per Dr. Pasieka. Retinoids will cause temporary retinoid dermatitis i.e. acne will look worse and skin will be drier. Too much of it will cause severe retinoid dermatitis. Benefit will not be seen in 2 weeks (dermatitis will be flaring at that time) so advise patients to not begin a regimen when an upcoming major event such as a wedding. Approximately 3 Months is when you will see the results.

If the patient is premenopausal, you must discuss pregnancy plans. Retinoids are teratogenic. In her practice, Dr. Pasieka counsels patients of reproductive age to stop using topical retinoids after a positive pregnancy test, even though risks are low. Oral contraceptive pills can treat both acne as well as give the patient a form of birth control. 

Scarring is an indication for isotretinoin. Someone who cannot get off of antibiotics without a flare needs to be on Isotretinoin and should be referred to dermatology. 

Rosacea

Key Characteristics: Papulopustular rosacea is a centrofacial manifestation, whereas acne will be more distributed on other aspects of face, per Dr. Pasieka.  Patients with rosacea will have a history of easy flushing and very sensitive skin. When it heals they will have blotchy erythema. Rosacea will not scar the same way as acne.  Rosacea is much more common in middle age, although may begin in 20s.

Erythematotelangiectatic (ETT) rosacea can be a mimic of SLE because it will also be bright red and spares the nasolabial area. ETT rosacea has a smouldering onset whereas SLE has a sudden onset of hours (or days) to weeks, per Dr. Pasieka. 

Kashlak Pearl:  When trying to assess ETT rosacea versus SLE, look at the hands. Hands receive tons of photo exposure and will frequently have a photosensitive rash that spares the knuckles in SLE. SLE patients may have ulcers in their mouth as well (expert opinion).

Treatment: Sun protection and heat protection are helpful in managing rosacea. Patients should use mineral based (zinc oxide or titanium oxide, or a blend) sunscreen for sensitive skin. Per Garbs, formulations with both zinc and titanium as opposed to all zinc tend to be easier to rub in.  Metronidazole 1% cream works reasonably well for papulopustular rosacea, but is ineffective for ETT rosacea. Sulfur washes are also an option for treatment.  Laser therapy or topical vasoconstriction can be helpful for ETT rosacea so those patients should be referred to dermatology.  Branded low-dose, long-acting doxycycline may benefit patients with papulopustular rosacea due to its anti-inflammatory properties. Since the long-acting doxycycline formulation may be unaffordable for some patients, one can substitute the immediate release 50mg doxycycline version, per Dr. Pasieka. 

Rosacea in Black Skin

We are lacking reference photos for rosacea in Black skin and the erythema may be harder for the untrained eye to detect (Onalaja, Cutis 2019). Because of this, rosacea in Black patients is underdiagnosed (Rosen, JAAD 1987) even though the global prevalence may be as high as 10 percent (Alexis, JAAD, 2019). Patients will report a lengthy history of sensitive skin, per Dr. Pasieka.  Ocular rosacea may also be another symptom of rosacea which can be present in non-white patients (Browning, Am Journ Ophtho 1986). It is worth noting that SLE causes increased mortality in Black patients (CDC 2019) and is suspected to be underdiagnosed in this population (Ippolito, Clin Exp Rheumatol 2008). 

‘Maskne’

Skin changes from mask wearing are a form of acne mechanica. It is a type of acne also seen in athletes from friction, sweat,  and moisture. Dr. Pasieka recommends sulfur washes,  and benzoyl peroxide (4% or higher). Dr. Pasieka also recommends using multiple masks and washing cloth masks frequently.  (Garbs recommends dipping wet q-tip in 100% tea tree oil  for Maskne spot treatment, it is straight up magical. Trader Joe’s also carries a dupe of this brand.)

Seeing Skin: Images of Common Skin Conditions

Scalp Psoriasis: 

https://dermnetnz.org/topics/psoriasis-of-the-scalp-images/

http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=395

Seborrhoeic Dermatitis:

http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=424

https://dermnetnz.org/topics/seborrhoeic-dermatitis/

Acne:

https://dermnetnz.org/topics/acne-face-images/

Rosacea:

http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=6

Lupus:

http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=266

https://dermnetnz.org/topics/systemic-lupus-erythematosus-images/

Links*

1. Hamilton and Alexander Hamilton by Ron Chernow, 
2. Serious Eats/The Food Lab’s Ultra-Gooey Stovetop Mac and Cheese Recipe (Beth’s Cheese Blend: 8oz American cheese, 8 oz Fontina, 8 oz cheddar- not Seriously Sharp!! Also, you may be able to get away with not using 1.5lb of cheese, mix in and see how it goes, feel free to DM @VermontKitchen on Instagram for cooking guidance) 
3. The Food Lab: Better Home Cooking Through Science by J. Kenji Lopez-Alt 
4. Mineral sunscreens: suggestions include Neutrogena Sensitive Skin Sunscreen or Elta MD UV Physical Broad-Spectrum Tinted Facial Sunscreen (Formulations with Zinc Oxide only tend to be very heavy and will not blend well in all skin tones) 
5. Brown Skin Matters on Twitter and Instagram
6. Skin of Color Society
7. American Academy of Dermatology
8. Society for Dermatology Hospitalists
9. Black Skin Directory Learning Journal
10. Mind the Gap (2020) by Malone Mukwende 
11. Ethnic Dermatology: Principles and Practice (2013)
12. Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment (2012)
13. An Atlas of African Dermatology (2001)

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goals

Listeners will appropriately recognize, diagnose and treat common dermatological complaints of the scalp and face seen in the primary care clinic.

Learning objectives

After listening to this episode listeners will…

1. Recognize and treat common skin complaints of the scalp and face in primary care.
2. Become familiar with the basic therapeutic arsenal to treat scalp and face complaints in primary care.
3. Be able to differentiate non-scarring versus scarring hair loss on physical exam.
4. Comprehend nuances in total body presentations of psoriasis as a means to differentiate from seborrheic dermatitis. 
5. Review when referral to dermatology for hair loss or skin changes of the face/scalp  is necessary.
6. Recognize the extreme lack of diversity in dermatology and disparities in outcomes for various diagnoses.

Disclosures

Dr. Pasieka reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Pasieka HB, Williams PN, Watto MF, Garbitelli EC. “#232 Skinternship – Scalp & Face” The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date September 14, 2020.