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!
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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).
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)
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.
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).
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.
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).
When assessing a flaking or greasy scalp complaint, you will need to assess the entire body for other potential patches.
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 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.
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.
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.
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.
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).
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.)
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Listeners will appropriately recognize, diagnose and treat common dermatological complaints of the scalp and face seen in the primary care clinic.
After listening to this episode listeners will…
Dr. Pasieka reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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.
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