Diagnosis of Hirsutism
Hirsutism Diagnosis: Book Excerpts
Diagnostic Tests for Hirsutism: Online Medical Books
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HIRSUTISM:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there clitoral enlargement or other signs of virilism? These findings would suggest an ovarian tumor, an adrenal tumor or hyperplasia, chromosome mosaicism, and true hermaphroditism, which is rare.
- Is there obesity? The presence of obesity and hirsutism should bring to mind Cushing's syndrome. However, it is also a sign of polycystic ovaries.
- Is there a history of the use of the steroids or other drugs? Adrenocortical steroids, testosterone, phenytoin, minoxidil, and diazoxide are just a few of the drugs that may cause hirsutism.
- Is there an ovarian mass? The presence of an ovarian mass should make one think of polycystic ovaries, an arrhenoblastoma, or granulosis cell tumor. Remember, there may be no ovarian mass in polycystic ovary syndrome (Stein-Leventhal syndrome).
DIAGNOSTIC WORKUP
The routine diagnostic workup includes a serum free testosterone, free cortisol, prolactin, a skull x-ray (much more economical than a CT scan or MRI of the brain), and a urinary gonadotrophin assay. If a pituitary tumor or lesion is strongly suspected, an FSH and LH should be done regardless of results of routine tests. An overnight dexamethasone test is more accurate than a routine free cortisol in diagnosing Cushing's syndrome. Pelvic ultrasound and CT scan of the abdomen would complete the workup, but why order these expensive diagnostic tests before consulting a gynecologist or endocrinologist?
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hirsutism:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Drug-induced
–Cyclosporin, steroids, oral contraceptives, Dilantin, some diuretics (acetazolamide, hydrochlorothiazide), Minoxidil, penicillamines
-
Syndrome-associated
–Cornelia de Lange syndrome
–Trisomy 18
–Hurler syndrome
–Bloom syndrome
–Seckel syndrome
–Marshall-Smith syndrome
–Rubinstein-Taybi syndrome
–Leprechaunism
-
Ovarian
–PCOS
–Gonadal dysgenesis
–Ovarian tumors
-
Adrenal
–CAH
–Cushing syndrome
–17α-hydroxylase deficiency
–21-hydroxylase deficiency
–Adrenal tumor
-
Other causes
–Idiopathic
–5 α-reductase deficiency
–Hyperprolactinemia
–HAIR-AN syndrome (hirsutism,
androgenization, insulin resistance, and
acanthosis nigricans)
–Achard-Thiers syndrome: Obesity and facial hirsutism develop by 15–30 years of age; hypertension and obesity occur later
–Porphyria: Congenital erythropoietic porphyria have increased body hair, red urine, photosensitivity with bullae, and red to pink teeth (werewolves of old)
Workup and Diagnosis
- History
–Age of onset (PCOS presents in teen years, CAH can
present in infancy or adulthood)
–GU development and menstrual history
–Associated symptoms such as stress, weight changes,
acne, voice changes
–Medications
–Family history of hair growth patterns or endocrine
abnormalities
-
Physical exam
–Vital signs and complete exam of all systems to evaluate for signs of androgen excess
–Breast exam and detailed GU exam
–Abdominal exam to rule out pelvic or adrenal mass
-
Labs
–If virilization is present, check serum testosterone level, 17-hydroxyprogesterone and dehydroepiandrosterone
–If patient is not pregnant, progesterone challenge test may be performed; patient should have withdrawal bleeding after cessation of progesterone
–If no withdrawal bleeding occurs after challenge, check levels of estradiol, FSH, LH, and prolactin
–LH:FSH ratio >2.5:1 in PCOS (low relative FSH does not allow androstenedione to be converted to estradiol in the ovary, resulting in androgen buildup and anovulation)
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Source: In A Page: Pediatric Signs and Symptoms, 2007
HIRSUTISM:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Clinically it is most important to look for obesity and virilism. A history of hypomenorrhea or amenorrhea is also important. The workup initially should include serum cortisol or 24-hour urine 17-hydroxycorticoids or 17-ketosteroids, and a thyroid profile. A skull x-ray and flat plate of the abdomen may be helpful. A cortisone suppression test may be required. An endocrinologist should be consulted before proceeding with CT scans of the brain, abdomen, and pelvis. A pituitary microadenoma may only be found by an MRI of the pituitary.
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Source: Differential Diagnosis in Primary Care, 2007
Weight gain, excessive:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced visual disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?
Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?
During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status, pages 644 and 645.) Note fat distribution and the presence of localized or generalized edema and overall nutritional status. Inspect for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Weight loss, excessive:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin with a thorough diet history because weight loss almost always is caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask him about previous weight and if the recent loss was intentional. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. For example, has he gotten separated or divorced? Has a family member or friend died recently? Has he recently changed jobs?
Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially any use of diet pills and laxatives.
Carefully check the patient’s height and weight, and ask about his previous weight. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident? Ask about exact weight changes (with approximate dates).
Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also, check the patient’s eyes for exophthalmos and his neck for swelling; evaluate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.
Conventional laboratory and radiologic investigations such as complete blood count, serum albumin levels, urinalysis, chest X-ray, and upper GI series usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hirsutism:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A family history of hirsutism, absence of menstrual abnormalities or signs of masculinization, and a normal pelvic examination strongly suggest idiopathic hirsutism. Tests for secondary hirsutism depend on associated symptoms that suggest an underlying disorder. About 90% of women with hirsutism have an elevated free testosterone level.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hirsutism:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by asking the patient where on her body she first noticed excessive hair. How old was she then? Where and how quickly did other hirsute areas develop? Does she use any hair removal technique? If so, how often does she use it, and when did she use it last? Next, obtain a menstrual history: the patient’s age at menarche, the duration of her periods, the usual amount of blood flow, and the number of days between periods.
Ask about medications, too. If the patient is taking a drug containing an androgen or progestin compound, or another drug that can cause hirsutism, find out its name, dosage, schedule, and therapeutic aim. Does she sometimes miss doses or take extra ones?
Next, examine the hirsute areas. Does excessive hair appear only on the upper lip or on other body parts as well? Is the hair fine and pigmented, or dense and coarse? Is the patient obese? Observe her for other signs of virilization.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Alopecia [Hair loss]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t receiving a chemotherapeutic drug or radiation therapy, begin by asking when he first noticed the hair loss or thinning. Does it affect the scalp alone, or does it occur elsewhere on the body? Is it accompanied by itching or rashes? Then carefully explore other signs and symptoms to help distinguish between normal and pathologic hair loss. Ask about recent weight change, anorexia, nausea, vomiting, excessive stress, and altered bowel habits. Also ask about urinary tract changes, such as hematuria or oliguria. Has the patient been especially tired or irritable? Does he have a cough or difficulty breathing? Ask about joint pain or stiffness and about heat or cold intolerance. Inquire about exposure to insecticides. If the patient is female, ask if she has had menstrual irregularities and note her pregnancy history. If the patient is male, ask about sexual dysfunction, such as decreased libido or impotence.
Next, ask about hair care. Does the patient frequently use a hot blow dryer or electric curlers? Does he periodically dye, bleach, or perm his hair? If the patient is black, ask if he uses a hot comb to straighten his hair or a long-toothed comb to achieve an Afro look. Does he ever braid the hair in cornrows? Check for a family history of alopecia, and ask what age relatives were when they started experiencing hair loss. Also ask about nervous habits, such as pulling the hair or twirling it around a finger.
Begin the physical examination by taking vital signs and then assessing the extent and pattern of scalp hair loss. Is it patchy or symmetrical? Is the hair surrounding a bald area brittle or lusterless? Is it a different color than other scalp hair? Does it fall out easily? Inspect the underlying skin for follicular openings, erythema, loss of pigment, scaling, induration, broken hair shafts, and hair regrowth.
Then examine the rest of the skin. Note the size, color, texture, and location of any lesions. Check for jaundice, edema, hyperpigmentation, pallor, or duskiness. Examine nails for vertical or horizontal pitting, thickening, brittleness, or whitening. As you do so, watch for fine tremors in the hands. Observe the patient for muscle weakness and ptosis. Palpate for lymphadenopathy, enlarged thyroid or salivary glands, and masses in the abdomen or chest.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Weight gain, excessive:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced visual disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?
Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?
During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status.) Note fat distribution, the presence of localized or generalized edema, and overall nutritional status. Examine the patient for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Weight loss, excessive:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin with a thorough diet history because weight loss is almost always caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask about his previous weight and whether the recent loss was intentional. Be alert for lifestyle or occupational changes that may be causing anxiety or depression. For example, has he gotten separated or divorced? Has he recently changed jobs?
Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially the use of diet pills or laxatives.
Carefully check the patient’s height and weight, and ask about exact weight changes with approximate dates. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident?
Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also, check the patient’s eyes for exophthalmos and his neck for swelling; auscultate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.
Conventional laboratory and radiologic tests, such as complete blood count, serum albumin levels, urinalysis, chest
X-rays, and upper GI series, usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hirsutism:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Onset. It is useful to determine the age of the onset of the hirsutism, its rate of progression, and the timing of any exacerbation of hair growth. The patient’s menstrual history, pregnancy history, or general medical history can yield important clues about an underlying endocrinopathy or another medical disorder.
B. Medications. A detailed medication history is important. Some medications cause hirsutism directly (e.g., androgenic oral contraceptives, anabolic steroids in body-builders) and can produce an increased libido. Others cause hirsutism indirectly by causing hyperprolactinemia (e.g., phenothiazines, tricyclic antidepressants), which can be associated with galactorrhea and menstrual abnormalities.
C. Family history. A familial pattern can be associated with idiopathic hirsutism, polycystic ovarian disease, and late-onset congenital adrenal hyperplasia.
Physical examination
A. Hair growth. The exact distribution of terminal hair growth should be noted. A male type escutcheon (hair filling the superior pubic triangle) is a presumptive sign of hyperandrogenism. Some patients will have had unwanted hair removed, altering the clinical presentation.
B. Secondary sexual characteristics. Pathologic androgen excess is suggested by acne, oily skin, and signs of virilization (frontal balding, deepening of the voice, increase in muscle mass, and clitoromegaly). This is especially true if defeminization (loss of breast tissue, vaginal atrophy) is also present.
C. Other findings. A bimanual pelvic examination may reveal ovarian enlargement. Obesity with acanthosis nigricans (dark, velvety hyperpigmentation of the axilla, groin, neck, umbilicus) is suggestive of the insulin-resistant form of polycystic ovarian disease. Corticosteroid excess can produce the signs of Cushing’s syndrome.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Alopecia/Hirsutism:
Differential Overview
(Field Guide to Bedside Diagnosis)
Alopecia
❑ Androgenetic
❑ Telogen effluvium
❑ Drugs/hair loss
❑ Anagen effluvium
❑ Alopecia areata
❑ Tinea capitis
❑ Traction
❑ Hypothyroidism
❑ Seborrheic dermatitis
❑ Discoid lupus
❑ Systemic lupus erythematosus
❑ Lichen planus
❑ Scleroderma
❑ Dietary deficiency
❑ Trichotillomania
❑ Syphilis
Hirsutism
❑ Idiopathic hirsutism
❑ Drugs/hair growth
❑ Hypertrichosis
❑ Hyperprolactinemia
❑ Polycystic ovary syndrome
❑ Cushing syndrome
❑ Adrenal tumor
❑ Ovarian tumor
❑ Ovarian hyperthecosis
Diagnostic Approach
Nonscarring alopecia includes androgenetic, telogen effluvium, trichotillomania, traction, aerata, and syphilis. Scarring alopecia is characterized by fibrosis, inflammation and loss of follicles, occurring with inflammatory dermatoses, deep infections, neoplasms, burns, and genodermatoses. Broken hair shafts are seen in fungal infections, traction, and trichotillomania.
Most hirsutism is familial. If a woman with hirsutism has normal menses, a family history of hirsutism, no virilization, and gradual onset, no further evaluation is needed.
Signs of androgen excess include defeminization with amenorrhea, decrease in breast size, or loss of female body contours more often than virilization. Other signs include acne, increased libido, clitoromegaly, temporal hair loss, deepened voice, and increased muscle mass. Acute onset of hirsutism and virilization suggests an androgen-producing adrenal or ovarian tumor, or exogenous androgen ingestion.
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Source: Field Guide to Bedside Diagnosis, 2007
Patterned Breathing:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Tachypnea
❑ Paroxysmal nocturnal dyspnea
❑ Sleep apnea
❑ Cheyne-Stokes
❑ Kussmaul
❑ Biot
❑ Apneustic
❑ Ataxic
❑ Stertorous
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Source: Field Guide to Bedside Diagnosis, 2007
Patterned Erythema:
Differential Overview
(Field Guide to Bedside Diagnosis)
Figurate
❑ Tinea corporis
❑ Urticaria
❑ Erysipelas
❑ Erythema migrans
❑ Secondary syphilis
❑ Livedo reticularis
❑ Erythema multiforme
❑ Cutaneous larva migrans
❑ Granuloma annulare
❑ Erythema marginatum
Photodistribution
❑ Sunburn
❑ Drugs
❑ Polymorphous light eruption
❑ Systemic lupus erythematosus
❑ Porphyria cutanea tarda
❑ Pellagra
Differentiate from Cellulitis
❑ Insect bite
❑ Acute gout
❑ Deep vein thrombophlebitis
❑ Erythema migrans
❑ Fixed drug eruption
❑ Pyoderma gangrenosa
❑ Sweet syndrome
❑ Necrotizing fasciitis
Diagnostic Approach
Sun-exposed areas of the face, the “V” of the neck (but not under the chin), and the dorsum of the hands and feet are common distributions for photodermatitis.
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Source: Field Guide to Bedside Diagnosis, 2007
Hirsutism:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by asking the patient where on her body she first noticed excessive hair. How old was she then? Where and how quickly did other hirsute areas develop? Does she use any hair removal technique? If so, how often does she use it, and when did she use it last? Next, obtain a menstrual history: the patient’s age at menarche, the duration of her menses, the usual amount of blood flow, and the number of days between menses.
Also ask about medications. If the patient is taking a drug containing an androgen or progestin compound, or another drug that can cause hirsutism, find out its name, dosage, schedule, and therapeutic aim. Does she sometimes miss doses or take extra ones?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Weight gain, excessive:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced vision disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?
Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?
CULTURAL CUE:Body weight is influenced by gender and race. For example, Black men tend to weigh less than White men and Black women tend to weigh more than White women of the same age. Socioeconomic status also affects weight gain. Individuals of lower socioeconomic status tend to have more pronounced obesity than those of middle-class or upper middle-class status.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Weight loss, excessive:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin with a thorough diet history because weight loss almost always is caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask him about previous weight and if the recent loss was intentional. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. For example, has he gotten separated or divorced? Has he recently changed jobs?
Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially use of diet pills and laxatives.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hair Loss:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Congenital Hair Loss
Localized
Nevus Sebaceous of Jadassohn
Appearson scalp as smooth, slightly raised, linear or oval, yellow or orange,waxy plaque, which is usually solitary.Because of possibility of developingsecondary tumors during puberty, excision is recommended beforepuberty. Aplasia Cutis Congenita
≥1 ovaldefects, 1–2 cm in diameter, appear as ulcerlike lesions,usually in midline of posterior scalp. Lesions sometimes have atrophicskin covering and generally heal in a scar without hair.Inheritance pattern is usually autosomaldominant but may be autosomal recessive. Congenital Triangular Alopecia
May go unnoticed until 2–3 yrs ofage. Triangular area of alopecia, which may be unilateral or bilateral,overlies frontotemporal suture and impinges on anterior hairline.Area remains unchanged throughout life.
Diffuse
Ectodermal Dysplasias
In X-linkedanhidrotic form of ectodermal dysplasia, affected boys have alopecia,hypotrichosis, lack of sweating due to absent sweat glands, andabnormal teeth (small pointed incisors or absence of teeth). Skinbiopsy that shows absence of sweat glands is confirmatory.Autosomal-dominant hidrotic form ischaracterized by variable focal alopecia or loss of all scalp hair,severe nail dystrophy (thick and brittle nails), normal sweating,and normal teeth. Gene locus has been mapped to chromosome 13q12.Rare type of ectodermal dysplasia iscartilage-hair hypoplasia, autosomal-recessive disorder of incompletepenetrance, in which individuals have fine, sparse hair; metaphysealdysplasia resulting in short stature; and immunodeficiency. See Chap. 53, Recurrent Infection. Hair Shaft Defects
Trichorrhexisnodosa produces hair that breaks easily, leaving broken stubs andareas of alopecia. Microscopic exam shows hair that looks like 2paint brushes pushed together. May be associated with argininosuccinicaciduria and Menkes disease.Pili torti refers to dry, lusterless,fragile hair, which can occur as autosomal-recessive disorder ormay be associated with Menkes disease. Microscopic exam revealsflattened hair shaft twisted on its own axis.Monilethrix is autosomal-dominant disordercharacterized by scalp hair breakage. Microscopic exam shows typicallybeaded hair.Scalp and body hair appears dry, lusterless,and fragile with trichorrhexis invaginata. Microscopic exam revealsbamboolike ball and cup joints. Can occur in Netherton disease,which is characterized by ichthyosis. Loose Anagen Hair Syndrome
Autosomal-dominant disorder with variableexpression in which hair is sparse, slow growing, usually fair colored,and easily pulled from scalp. Hair shafts have reduced caliber.Electron microscopy shows slight flattening and longitudinal groovingof hair.
Congenital Hypothyroidism
Scalp hair may be sparse and brittle. See Chap. 23, Growth Deficiency: Weight and Height.
Acquired Hair Loss
Localized
Traction Alopecia
Excessivetension on hair shafts can cause hair loss, and most cases are relatedto hair care. Broken hairs of various sizes are seen in areas ofalopecia.Friction alopecia occurs from repeatedrubbing of scalp and is seen in infants who lie for prolonged timeon their backs or who repetitively rub back of their heads as dailyritual. Trichotillomania
Compulsivepulling of scalp hair, eyebrows, or eyelashes. Habitual, possiblyrelated to underlying anxiety.Irregular patches of hair loss occur,while residual hairs of varying length remain.Psychologic treatment is sometimesnecessary. Tinea Capitis
T. tonsuransis most common cause of tinea capitis in North America. M. canisacquired from kittens or puppies may also cause tinea capitis. Severalpresentations may occur:Circumscribed areas of hair loss with hairsbroken off at follicular orifice (black dot sign) and no other scalpchangeDiffuse fine scaling in dandruff-likepattern without obvious broken off hairsMultiple patches of hair loss withindistinct margins accompanied by kerion (boggy, erythematous nodulewith superficial pustules)Multiple kerions Diagnosis may be confirmed by KOH preparationor fungal culture. Injury
Physical trauma or burns severe enough tocause scarring can produce localized alopecia.
Alopecia Areata
Autosomal-dominantdisorder in which complete or almost complete hair loss occurs incircumscribed areas. Autoimmune mechanism is thought to be responsible.Loss of body hair, eyebrows, and eyelashesalso may be seen. Patches of hair loss do not have any hair exceptperhaps some loose ones at margins. In most cases of incompletehair loss, regrowth of hair usually occurs within 1 yr. With extensivehair loss, prognosis is uncertain.Diagnosis can be confirmed by biopsy. Other
Localizedscalp lesions sometimes occur with varicella, pyoderma, lichen planus,discoid lupus erythematosus, secondary syphilis, and psoriasis.See Chap. 60, Skin Lesions andRashes.Morphea is scleroderma localized toskin. Scalp lesions are linear or oval and often extend from foreheadinto frontal scalp, producing scarring hair loss. Skin is immobile,shiny, hypopigmented, and often surrounded by purplish border. Skinbiopsy is diagnostic. Diffuse
Telogen Effluvium
Characterizedby hair loss resulting from various stresses that cause cessationof hair growth. Such stresses include febrile or chronic illness,general anesthesia, severe injury, drugs (propranolol, coumadin,heparin, valproic acid), and psychologic disturbances. Time betweenstress and hair loss is 2–4 mos.Telogen hairs have absent or fragmentedexternal root sheaths, which often lack pigment. Root of hair isnarrower than shaft and is often curved.Presence of >25% oftelogen hairs in sample of plucked hairs is diagnostic. Anagen Effluvium
Temporaryarrest of follicular activity produced by a substance or physicalmodality that is toxic to hair follicle. Onset of increased sheddingand hair loss usually occurs 1–2 wks after exposure.Anagen hair has pigmented core andbulbous root, which is larger in diameter than hair shaft.Most common causes of anagen hair lossare chemotherapeutic agents that interfere with hair growth (methotrexate,5-fluorouracil, nitrogen mustard, chlorambucil, vincristine, cyclophosphamide,actinomycin D, vinblastine) and radiation that damages growing hair.History and microscopic observationthat most of the lost hairs are in anagen phase confirm diagnosis. Androgenetic Alopecia
In boys, there is thinning over vertex andbifrontal areas of scalp, whereas in girls the crown thins. Geneticallydetermined and potentiated by androgens.
Diagnostic Approach
Diagnosisof hair loss in children can often be made by history and physicalexam.About 90–95% of casesinvolve acquired localized hair loss with tinea capitis, traction alopecia,trichotillomania, or alopecia areata.Diagnosis of tinea capitis is usuallyclinical, but if diagnosis is uncertain, KOH preparation can beperformed. If results are negative, fungal culture should be performed.Most diffuse hair loss is acquired,and most common causes are anagen effluvium (usually chemotherapeuticagents) and telogen effluvium. History and microscopic exam of hairis usually diagnostic of anagen or telogen effluvium.Hair shaft defects also can cause diffusehair loss, but they are rare. Diagnosis is made by microscopic examof hair.Skin biopsy is often necessary in diagnosisof unusual lesions (e.g., aplasia cutis congenita, lichen planus,discoid lupus erythematosus, and morphea).
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Weight gain, excessive:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Determine your patient's previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Ask about associated symptoms. Has the patient experienced vision disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation? Is she menopausal or postmenopausal?
Form an impression of the patient's mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he taking?
During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status, pages 644 and 645.) Note fat distribution and the presence of localized or generalized edema and overall nutritional status. Inspect for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient's vital signs.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Weight loss, excessive:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin with a thorough diet history because weight loss is almost always caused by inadequate caloric intake. If the patient hasn't been eating properly, try to determine why. Ask him about previous weight and whether the recent loss was intentional. Determine how long the weight loss has been taking place. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. Has the patient recently experienced a loss?
Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Has he been experiencing other pain? If so, ask about the location of the pain and how long he has had it. Take a careful drug history, noting especially use of diet pills and laxatives.
Carefully check the patient's height and weight and ask about his previous weight. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident? Ask about exact weight changes (with approximate dates).
Examine the patient's skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth and note hyperpigmentation of the buccal mucosa. Check the patient's eyes for exophthalmos and his neck for swelling; evaluate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.
Conventional laboratory and radiologic investigations such as complete blood count, serum albumin levels, urinalysis, chest X-ray, and upper GI series usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
HIRSUTISM:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Clinically it is most important to look for obesity and virilism. A
history of hypomenorrhea or amenorrhea is also important. The workup
initially should include serum cortisol or 24-hour urine
17-hydroxycorticoids or 17-ketosteroids, and a thyroid profile. A skull
x-ray and flat plate of the abdomen may be helpful. A cortisone suppression
test may be required. An endocrinologist should be consulted before
proceeding with CT scans of the brain, abdomen, and pelvis. A pituitary
microadenoma may only be found by an MRI of the pituitary.
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Source: Differential Diagnosis in Primary Care, 2007
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