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Primary Care RAP February 2019 Written Summary

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Primary Care RAP February 2019 Written Summary Primary Care RAP February 2019 Written Summary Editor-in-Chief: Neda Frayha MD ​ Associate Editor: Kenji Taylor MD, MSc ​ Intro: Female Alopecia Aisha Lofters MD, Neda Frayha MD Pearls: ● Androgenetic alopecia is the most common form of hair loss for both men and women. ● A good history and physical that includes examining the presence or absence of hair follicles is generally sufficient for diagnosis. ● For women, the only evidence-based treatment is topical 2% minoxidil. ● Hair follicle: ○ 3 stages ■ Anagen (growth), 80-90% of hair follicles should be in this state ■ Catagen (transition) ■ Telogen (resting) ○ Normal shedding is 100 hairs per day ● History of hair loss: ○ Duration - acute or chronic ○ Pattern - diffuse or one spot ○ Any changes - meds, diet ○ Family history ● Physical ○ Examine scalp for erythema or inflammation or scaling ○ Examine follicles: are they present or are they absent (scarred) ○ Examine distribution of hair ○ Pull test: take about 60 hairs between thumb/index/middle fingers and give a pull. Negative ​ test is if 6 or fewer hairs come out in your hand which is consistent with normal shedding. Patient should not have washed hair for 24 hours. ○ Look for signs of androgen excess (acne, hirsutism) ● Diagnostics ○ Biopsy indicated if you don’t see hair follicles and instead see scarring → punch biopsy can help diagnose lupus, sarcoid, fungal infection or cancers. If biopsy nondiagnostic, start thinking about hereditary disorders or trauma (burns, radiation). ○ If androgen excess: total and free testosterone, DHEA, prolactin ○ Other labs: TSH, ANA, ferritin, VDRL, vitamin D ● Androgenetic alopecia ○ Most common form for men and women ○ In the presence of androgens, genes that shorten the anagen (growth) phase are going to be activated leading to less growth, shorter and thinner hair ○ Worse in frontal and parietal areas Primary Care RAP February 2019 Written Summary | hippoed.com/pc 1 ​ ​ ○ For women, not usually going to be lots of hormonal imbalance so doing hormonal workup is low yield unless other signs of androgen excess ○ No relation to frequency of washing hair ○ Treatment: ■ Minoxidil 2% - increases time follicles spend in growth phase, wakes up out of resting phase and enlarged the follicles themselves. ● One double-blind randomized control trial showed 50% had minimal hair growth and 13% and moderate hair growth compared to placebo ● Hair growth more pronounced at vertex than frontal areas ● Takes about 4 months to really show ● If patient stops taking it, hair loss resumes pretty quickly ● 5% dose more effective in men but shown to have more side effects in women (ie: more hair growth in other areas on the face). No good literature to support this dose in women. ■ Spironolactone - questionable data, consider in those with androgen excess ■ Finasteride - used in men but not women, especially of child-bearing age because of teratogenicity ■ Latanoprost - prostaglandin analog used for glaucoma showing early data that it increases hair density but not mainstream ■ Transdermal injections of plasma rich in growth factor in Spain ■ Vitamins like biotin - no data substantiates their benefit. Biotin may impair thyroid assays ■ Hair transplant from one part of the scalp to another has good cosmetic outcomes but is expensive ● Other types: ○ Alopecia areata - autoimmune condition presents as well circumscribed oval patches of hair loss with exclamation point hairs at the periphery of the patch ■ Spontaneous recurrence and remission ■ Treated with intralesional steroids and topical anthralin cream ○ Telogen effluvium - diffuse hair loss caused by anything that shifts the follicles from anagen to telogen. Patients complain of lots of hair loss on pillow or in shower/tub ■ Common causes of stress, childbirth, hypothyroidism, severe infection, drugs (heparin, ACE inhibitors, anticonvulsants) ■ Hair will regrow on its own over time ○ Traumatic alopecia - traction from tight braiding or harsh brushes or trichotillomania Reference: https://www.aafp.org/afp/2003/0301/p1007.html https://www.aafp.org/afp/2003/0701/p93.html https://www.aafp.org/afp/2009/0815/p356.html https://www.aafp.org/afp/2017/0915/p371.html https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582478/ Jacobs JP, Szpunar CA, Warner ML. Use of topical minoxidil therapy for androgenetic alopecia in women. Int J Dermatol. 1993;32:758–62. ​ ​ Primary Care RAP February 2019 Written Summary | hippoed.com/pc 2 ​ ​ DeVillez RL, Jacobs JP, Szpunar CA, Warner ML. Androgenetic alopecia in the female. Treatment with 2% topical minoxidil solution. Arch Dermatol. 1994;130:303–7. ​ ​ Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad ​ Dermatol. 2008 Oct. 59(4):547-66; quiz 567-8. ​ Motofei IG, Rowland DL, Baconi DL, et al. Androgenetic alopecia; drug safety and therapeutic strategies. Expert Opin Drug Saf. 2018 Jan 24. ​ ​ https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1610-0379.2011.07802.x http://jddonline.com/articles/dermatology/S1545961614P0809X/1 Asymptomatic Hypertension Matthew Delaney MD & Joe Martinez MD Pearls: ❏ Blood pressure control is important, but it's most important in the longer term and patients can suffer adverse events if it is lowered too quickly. Terminology: ● Hypertensive emergency - hypertension which causes end organ damage: ○ ACS - STEMI/NSTEMI ○ Aortic dissection ○ Renal failure ○ Pulmonary edema ○ Encephalopathy or stroke ○ Eclampsia ● Hypertensive urgency - patients with a systolic BP ≥180 or a diastolic ≥110 mmHg who are ​ minimally symptomatic or asymptomatic and have no evidence of end organ damage. Management ● Patients who are truly asymptomatic and who are not at significant risk for developing rapidly progressive target organ damage should follow up with their PCP for blood pressure management. ● Evaluate for potential causes of elevated hypertension such as pain, substance withdrawal or rebound hypertension from stopping blood pressure medications. ● The American College of Emergency Physicians states that for asymptomatic patients with markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) and routine ED medical intervention is not required. ● There is overwhelming evidence that the short term risk of adverse events for patients with asymptomatic hypertension is exceptionally low and hospitalization is of no benefit: Primary Care RAP February 2019 Written Summary | hippoed.com/pc 3 ​ ​ ○ A 2016 JAMA study found that patients who were sent to the hospital for hypertensive urgency had similar rates of major adverse cardiovascular events (MACE) compared to those that were sent home. The rates of MACE in both groups was extremely low as well at ~1% (Patel et al, 2016). ○ A study published by Masood et al. in 2016 in the Annals of Emergency Medicine found that in a retrospective cohort of patients that were sent to the ED with asymptomatic hypertension only 8% were admitted. The risk of mortality was similar between the group sent home versus those that were admitted ( 1% within 90 days, 2.5% within a year, 4% in 2 years). ● In the entirety of the medical literature, there's never been a single study to show that abruptly reducing blood pressure is beneficial for patients that are asymptomatic, but there's been myriads of studies that show that it has the great potential to cause harm. Reference: 1. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2527389 2. https://www.acep.org/patient-care/clinical-policies/asymptomatic-elevated-blood-pressu re/#sm.00000dnhqhmnuzf3guaxypz8x2i5z 3. http://journals.sagepub.com/doi/abs/10.1177/1060028016644756 4. 2017 Guideline for the Prevention, Detection, Evaluation, and ... Personality Disorders Part 1 and 2: Tricks of the Trade Shawn Hersevoort MD, Mizuho Spangler DO Pearls: ● Personality disorders are common in primary care. ● They are clustered into A (weird), B (wild) and C (worried). For A and B types, you may need to give less time. For C types, they may need more time to feel taken care of. In all instances, keep yourself safe (emotionally and physically) and document well. ● Other than dialectical behavior therapy for borderline personality disorders, there is no “treatment”. Accepting and working with these patients in-house is probably the best approach. ● Personality - individual pattern of thoughts, emotions and behaviors which tend to be stable over ​ time ● Personality disorder - markedly inflexible deviation in personality from cultural norms that are ​ manifested in at least two areas (cognition, affect, interpersonal functioning and interpersonal control) and cause significant trouble/impairment, usually beginning by adolescence or early adulthood ○ About 4% in the US fit criteria for personality disorders ○ About 1% are severe Primary Care RAP February 2019 Written Summary | hippoed.com/pc 4 ​ ​ ○ Up to 10% in primary care settings with variation depending on type of primary care setting ○ Up to 50% in psychiatry settings ○ Up to 70% in the prison setting ○ Generally come from neglect, abuse, especially with cluster B ● Clusters: ​ ○ A (weird) ■ Paranoid ■ Schizoid ■ Schizotypal ○ B (wild) ■ Histrionic - dramatic and emotional, needs to get all the attention ■ Narcissistic - grandiose, has to be the ‘most’ ■ Borderline - labile and shifting mood, impulsive; often confused with bipolar disorder ■ Antisocial - love to violate rules and rights not because they’re labile ○ C (worried) ■ Avoidant ■ Dependent ■ Obsessive-compulsive ● “Difficult Patient”
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