#492 Hair and Nails with Helena Pasieka MD MS

July 21, 2025 | By Kate Grant

Audio

Video

Transcript available via YouTube

Combing through common dermatologic complaints in Primary Care

Hone your framework for assessing generalized and patchy hair loss and learn how to counsel patients about the hair loss advice they hear on social media. We discuss useful tests and treatments, psychosocial factors in relation to hair loss, variations in hair types and mention relevant nail conditions. 

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Show Segments

• Intro
• Examination of hair and nails, ethnic hair types and cultural hair styles and practices.
• Lab tests- clinically useful tests, and those to avoid
• Telogen Effluvium
• Scaly itchy scalp, seborrheic dermatosis, psoriasis
• Androgenic alopecia and age-related hair loss
• Topical and oral treatments
• Examining the nails, conditions related to nail polishes and prosthetics
• Patchy hair loss, alopecia areata, Discoid Lupus Erythematosis
• Dr Pasieka’s take home points
• Outro

Disclosures

Dr. Pasieka reports no relevant financial disclosures. Dr. Pasieka’s views are her own and do not represent those of her employer or the department of defense. 

The Curbsiders report no relevant financial disclosures. 

Hair & Nail Pearls

1. Be sensitive to the psychosocial element of hair loss, both when examining patients, describing hair and scalp findings and the practical, emotional and financial impact of hair loss treatments.
2. Educate yourself about different ethnic and cultural hair textures and styling practices. Dr Pasieka has recommended a book listed below
3. Be aware that some topical treatments such as ketoconazole 2% shampoo can damage kinky/coily/dry hair types if used too frequently and other formulations or approaches might be needed, such as using topical steroid lotions to the scalp. 
4. Dr Pasieka makes general mention of hair care and styling products that claim to promote hair growth. They can contain enhancements like caffeine, rosemary or lavender essential oils, and products promoted by social media influencers.  No specific products are named, but expert opinion is to  avoid  recommending commercially available hair and scalp products when not backed by science.
5. Hair re-growth is slow. Advise patients to mark their calendar in 16 weeks, as new hair is unlikely to be seen sooner after commencing treatment.
6. Useful blood tests in a hair loss eval: complete blood count, ferritin, vitamin D and thyroid function.
7. Sex hormone assays are less helpful because we lack specifics on how levels correlate to hair loss and treatment outcomes. 
8. Anti-nuclear antibody is not recommended for hair loss, unless lupus is suspected from other clinical features.  

Hair and Nails 

Examination and History

• Approach patients sensitively– request permission to touch hair, nails and skin. Include an evaluation of skin and nails in all hair assessments.
• If  the examination involves taking down a hairstyle or removing head coverings or hairpieces, provide a small mirror in your office so they can replace style before they leave.
• Learn about cultural styling practices, as well as textured, kinky and curly hair types. Ask about heat or chemical treatment. Remember that different hair types need different washing and styling frequencies, therefore recommended treatments will also differ. (E.g ketoconazole 2% shampoo can be drying and cause breakage with frequent use in kinky/coily hair types. Suggest topical steroid to scalp instead). Avoid giving inappropriate advice from lack of education– this is a way to lose trust with patients.. [5][6] 
• Dr Pasieka recommends “Fundamentals of Ethnic Hair” (Ague and Okoye, 2018) for further reading.
• Hair assessment: Distinguish between root loss or shaft breakage and diffuse or patchy pattern loss. Share  your hair exam out loud; stating your negative findings can reassure the patient.
• Scalp assessment: Ask about itch, scale, cellulitis, and weeping. Identify common patterns of patchy loss, and look for evidence of regrowth or scarring of follicles.
• Nail examination: Request patients remove polish and nail prosthetics in advance of the appointment to adequately examine all 20 nails.
• Dr Pasieka does not think it is essential for primary care providers to have a dermatoscope for a hair and nail assessment.
• Hair loss can have a significant psychosocial and emotional impact,  [1] [2]  [3]  [4] 

Lab tests

• Blood tests: consider CBC, ferritin, vitamin D, TSH. Dr Pasieka avoids ordering anti-nuclear antibody testing as a screening test unless there is a clear suspicion of lupus. 
• Be aware that biotin supplements can interfere with other lab tests including troponin, thyroid and BNP. 
• Nail clippings can help to diagnose fungal infections in the nails.

Hormones and hair loss

• Dr. Pasieka avoids checking hormone levels for patients because there is no clear evidence about what levels affect hair loss/growth, nor do they inform how to reach treatment goals. She suggests partnering with other specialties if the patient has endocrine issues like diabetes, menopause or thyroid disease, or if they are taking contraception.
• Consider ‘hormone adjacent’ treatments which can promote hair growth in suitable patients.
  • Spironolactone 100-200mg daily, (not in women of childbearing age, since it can cause feminization of the male fetus)
  • Finasteride 1mg daily with counselling: Finasteride should not be used to promote hair growth  in men trying to conceive, it can reduce sperm count and irreversible erectile dysfunction is listed as a potential side effect.

Diagnoses

Telogen effluvium

• Generalised hair thinning occurring typically at times of increased stress. Patients report increased hair loss shed from the root, rather than shaft breakage. It is noticed  on the pillow, noticing more shedding in the shower, hair brush etc. 
• Telogen effluvium is accelerated by metabolic,  nutritional, hormonal (e.g. pregnancy and puerperium) physiological, psychological stress, and if these are addressed, hair growth usually returns. [see slides 8,9,10]
• Patients may be reassured by taking blood tests for CBC, ferritin, TSH and Vitamin D, because if abnormal, can be addressed with some benefit to hair regrowth.

Androgenic alopecia

• Various patterns (see slides 3, 4, 5, 13, 14, 15]
• There is miniaturization of the hair follicle and individual hairs become finer and sebaceous glands change and make the scalp appear shinier. 
• Often runs in families. 
• Treatment options can include minoxidil, scalp camouflage.
• Topical Minoxidil-Dr Pasieka recommends 5% for both men and women. Typically, women are prescribed Minoxidil 2-3% topical lotion. Consistent use is important to get results. Paradoxical hair loss can occur initially, regrowth takes 12 to 16 weeks later. Stop if no change after 16 to 20 weeks.  Dr Pasieka notes that if compliance is good and the scalp is responding, patients can be switched to oral minoxidil 1.25mg daily after 4-6 months, and she recommended screening for cardiovascular disease, hypotension and orthostatic symptoms, since minoxidil can lower BP and also cause dependent oedema. Motivated patients may feel empowered by doing something that can kickstart regrowth, it will not make things worse. This might be preferable to spending a lot of money on  shampoos and supplements.

Alopecia areata  [9] [11]

• Autoimmune. (see slide 7, 17)
• Can resolve or become permanent. 
• Can be scarring with loss of follicular ostia, or non scarring.
• Hair pull test positive if >6 hairs come out when tugged
• Patches can expand rapidly/ refer to dermatology early.
• Prompt treatment with potent topical steroids can help, e.g. Clobetasol ointment twice daily under occlusion, or oral steroids can be started in primary care
• Intralesional steroid injections, oral steroids, JAK-2 inhibitors are options in secondary care. 

Lupus Erythematosis/Discoid Lupus Erythematosis

• Autoimmune
• Scarring with permanent hair loss (see slide 18)
• Refer to dermatology. Intralesional steroid injections, oral steroids are considered in secondary care

Flaky, itchy scalp

• Seborrheic dermatitis (check eyebrows, nasolabial folds and around ears). Yellowish greasy scaly
• Ketoconazole 2% shampoo for fungal scalp dermatoses, and used as a skin wash for seborrheic dermatitis
• Psoriasis Scalp assessment: (Auspitz’s sign – pinpoint bleeding seen if you lift psoriatic scale), Look for a micacious scale on a red base with a clear border. Often spreads outside the hairline down onto the forehead and nape of neck. [see photo]

Hair loss as a function of ageing

• This is a natural ageing process for each sex. Even, for example, when minoxidil has been effective, once discontinued the hair state will return to what was pre-determined by genetics. Discontinuing treatment does not promote more hair loss beyond the predicted baseline state (see slides 3-7).

Hair transplant and other scalp treatments

• Follicles can be successfully transplanted from the occipital area to other parts of the scalp.
• Scalp micro-needling: Dr Pasieka discusses mode of action, that injury to the hair follicles and the hair follicle bulbs can promote inflammation which stimulates re-growth of hair.
• Home micro-needling kits are commercially available but have a risk of scalp cellulitis when patients report re-using the tips so this practice should be discouraged. 
• Micro-needling in conjunction with other scalp treatments such as topical steroid, platelet-rich-plasma and minoxidil can augment results [7]  [8]  

Commercially available (OTC) shampoos and styling products. 

• Commercially available shampoos, products containing caffeine, essential oils and styling products promise a lot, but Dr Pasieka says there’s little evidence that they promote hair re-growth. These products can be continued if it is part of the self care and general wellness routine. Patients often invest considerable emotional and financial effort into haircare; so be supportive, but avoid non-scientific recommendations. 
• Dr Pasieka mentions that using natural products without parabens and Sodium-Laural-sulfate (SLS) can be associated with more seborrheic dermatitis, so switching back from natural to standard haircare at times can help without requiring more medicated shampoos.
• Recommend hats and SPF to patients with areas of exposed scale

Patient counseling

• Hair recovery is slow! When starting a treatment plan for hair loss, Dr Pasieka’s expert advice suggests patients mark their calendar for 16 weeks from start of treatment as the time to start seeing any regrowth.
• Telogen effluvium is accelerated by metabolic, physiological, psychological stress, and if these are addressed, hair growth usually returns.

Notes about Acrylic Nails/prosthetics

• Acrylic nails: Be aware that repeated UV-light exposure used when curing cosmetic nail applications can bring a risk for squamous cell carcinoma
•  Acrylates can cause allergic sensitization, and are sometimes associated with facial dermatitis through touching.  Dr David Orton, of the British Association of Dermatologists, has said: “ developing an allergy to these chemicals can have lifelong consequences for dental treatments and surgeries where devices containing these allergens are in common use.”  [14]

Take-home points, 

• Up-skilling your knowledge about ethnic and textured hair types is good practice. Hair care practices and treatments are very different between types.
• It is essential to be sensitive and acknowledge the psychosocial impact of hair loss. Remember that people spend a lot of emotional energy and finances on their hair, so try to recommend evidence based practice, good science and don’t belittle patients for trying products with limited evidence. Direct proactive patients towards useful treatments.
• Get into the habit of reminding patients that it takes 16 weeks for new hair growth to appear.

Link to Dr Pasieka’s Hair & Nails clinical photos

Links & Citations

Fundamentals of Ethnic Hair: The Dermatologist’s Perspective: 9783319833514

General Dermatology & Psychosocial Impact

1. DermNet. Dermatology Life Quality Index (DLQI).
   https://dermnetnz.org/topics/dermatology-life-quality-index-dlqi
2. DermNet. Psychosocial Factors in Dermatology.
   https://dermnetnz.org/topics/psychosocial-factors-in-dermatology
3. DermNet. Psychological Effects of Hair Loss.
   https://dermnetnz.org/topics/psychological-effects-of-hair-loss
4. Changing Faces. Guidance for Health & Social Care Professionals Supporting Patients.
   https://www.changingfaces.org.uk/for-professionals/health-social-care-professionals/guidance-supporting-patients

Haircare

5. American Academy of Dermatology (AAD). Hair Care for African American Hair.
   https://www.aad.org/public/everyday-care/hair-scalp-care/hair/care-african-american
6. AAD. Hairstyles That Pull Can Lead to Hair Loss.
   https://www.aad.org/public/diseases/hair-loss/causes/hairstyles

Scalp Treatments

7. DermNet. Platelet-Rich Plasma: Dermatological Applications.
   https://dermnetnz.org/topics/platelet-rich-plasma-dermatological-applications
8. Gentile, P., & Garcovich, S. (2017). Platelet-rich plasma, the ultimate secret for youthful skin elixir and hair growth triggering. Stem Cell Investigation, 4, 64.
   https://pubmed.ncbi.nlm.nih.gov/28887865/

Alopecia Areata & Lupus Erythematosus

9. Jabbari, A., et al. (2015). Reversal of Alopecia Areata Following Treatment With the JAK1/2 Inhibitor Baricitinib.
   https://pubmed.ncbi.nlm.nih.gov/26137574/
10. British Association of Dermatologists. Alopecia Areata – Patient Management Pathway Flowchart.
    https://cdn.bad.org.uk/uploads/2021/12/09093626/Patient-Management-Pathway-flowchart.pdf
11. King, B., et al. (2023). Efficacy and Safety of Ritlecitinib in Adults and Adolescents with Alopecia Areata: A Randomised, Double-Blind, Multicentre, Phase 2b–3 Trial. The Lancet.
    https://pubmed.ncbi.nlm.nih.gov/37062298/
12. Vañó-Galván, S., et al. (2020). Management of Frontal Fibrosing Alopecia. International Journal of Women’s Dermatology, 6(5), 399–411.
    https://pmc.ncbi.nlm.nih.gov/articles/PMC7718862/
13. Primary Care Dermatology Society. Clinical Guidance: Lupus Erythematosus.
    https://www.pcds.org.uk/clinical-guidance/lupus-erythematosus
14. British Association of Dermatologists. (2021). Warning About UK Artificial Nail Allergy Epidemic.
    https://www.bad.org.uk/dermatologists-issue-warning-about-uk-artificial-nail-allergy-epidemic/
15. Darwin, E., et al. (2018). The Role of Inflammatory Pathways in Alopecia Areata.
    https://pubmed.ncbi.nlm.nih.gov/29769777/
16. https://dermnetnz.org/

Goal

Listeners will develop a framework to approach the different types of temporary and permanent hair loss, in different ages and ethnicities.

Learning objectives

After listening to this episode listeners will…  

1. Be confident discussing  different ethnic and cultural hair textures, types and styling needs
2. Learn a calm and reassuring approach to hair loss management, as well as patient information resources.
3. Minimise unnecessary investigations, and have realistic expectations about treatment outcomes.

Citation

Grant CE, Pasieka H B, Williams PN, Watto MF. #492 Hair & Nails”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date July 21, 2025.