Hair and Nail Assessment: A Primary Care Guide with Dr. Helena Pasieka

Comprehensive Hair and Scalp Assessment

• 💡 Start with the hands and nails as a culturally appropriate way to begin a physical exam before examining the scalp.
• 📌 Assess for pinning or ridging in the nails as a standard part of the hair exam.
• 🔍 Inquire about hair styling practices, heat treatments, and chemical use, especially for textured hair types.
• 🧠 Focus history-taking on nutritional status, hormonal shifts, and major life stressors as common causes of hair loss in primary care.

Differentiating Hair Loss Causes

• ⚖️ Distinguish between hair shedding from the root versus fragility and breakage.
• 📉 Consider telogen effluvium due to hypocaloric states, restrictive diets, or significant stress.
• 🧪 For blood tests, focus on CBC for anemia and ferritin, vitamin D, and TSH for yield and cost-effectiveness, avoiding ANA unless other symptoms are present.
• ⏳ Be patient with treatment: hair growth takes at least 16 weeks to show initial signs of improvement.

Seborrheic Dermatitis vs. Psoriasis

• 🧼 Seborrheic dermatitis typically presents with waxy, yellowish scale on the scalp, eyebrows, and nasolabial folds.
• 🌟 Scalp psoriasis can have a drier, more silvery scale and may extend beyond the hairline, potentially causing pinpoint bleeding.
• 🧴 Treatment for seborrheic dermatitis often involves medicated shampoos (ketoconazole, ciclopirox) and can be used as a face wash; topical steroids may be needed for drier hair types.
• 🔬 For suspected psoriasis, a high-potency topical steroid solution can be initiated, with referral to dermatology for severe cases or consideration of biologics.

Androgenic Alopecia and Hormonal Considerations

• 📈 Androgenic alopecia in women often presents as widening of the central part and thinning on the top of the head due to follicle miniaturization.
• 🚫 Hormone testing is generally not recommended unless there are specific indications for endocrinology referral; focus on treatments instead.
• 💊 Consider spironolactone or oral contraceptives containing estrogen for women, and topical or oral finasteride/dutasteride for post-menopausal women, with appropriate counseling on teratogenicity.
• 💇‍♀️ Hair transplantation is a viable, permanent option for motivated patients with androgenic alopecia.

Other Hair Loss Conditions and Treatments

• ⚠️ Alopecia areata is an autoimmune condition causing patchy, smooth hair loss; treatment can include potent topical steroids or oral JAK inhibitors for severe cases.
• 🩸 Discoid lupus on the scalp can cause scarring and permanent hair loss, requiring assertive treatment.
• 🧪 Minoxidil (topical or low-dose oral) is a common treatment for various types of hair loss, but requires consistent use and patience for results.
• 💡 Microneedling may promote hair growth by stimulating the Wnt signaling pathway, but requires sterile technique to avoid infection.
• 🚫 Exosomes and secretomes are not yet FDA-approved and are not recommended for clinical use in the US.