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Approximately 80% of women are affected by the presence of excessive hair growth in a 'male-like' pattern. Excessive facial hair in particular can be a source of distress to such women and can lead to psychological problems such as anxiety, depression and a reduced quality of life.Current cosmetic methods of hair removal include shaving, depilatories, waxing, plucking, laser, intense pulsed light (IPL) and electrolysis.A topical treatment cream such as eflornithine 11.5% can slow hair growth and thus reduce the frequency of the need for hair removal. This treatment can be used effectively in conjunction with hair removal methods.

Pili annulati is a rare autosomal inherited hair shaft abnormality of unknown pathogenesis in which clinical examination reveals alternating light and dark bands leading to a shiny appearance of the hair due to cavities within the cortex of the hair shaft. This is the first investigation of the proposed cytokeratin defect in pili annulati hair follicles. Four cryopreserved pili annulati and four control scalp specimens were analysed using immunohistochemistry for different 'hard' trichocytic and 'soft' epithelial cytokeratins including K1, K6, K10, K14, K16, K17, K18, K19, Ha1 and Hb1. There was no difference in staining intensity and quality of staining pattern seen in pili annulati and control scalp specimens. These results suggest that pili annulati is not caused by a defect of the cytokeratins investigated in this study.

A feature of black African hair is an apparent increased fragility of the hair shaft compared to other ethnic groups (as measured by the tensile force needed to break the hair fibre). This has certain similarities to that reported for trichorrhexis nodosa (weathering secondary to physical damage) and trichothiodystrophy [a genetic disorder associated with reduced cystine (sulphur)-rich proteins and increased fragility]. In the present study, the distribution of the cystine-rich proteins in the hair of black Africans was compared to that of Caucasian and Asian volunteers, plus patients with trichorrhexis nodosa and trichothiodystrophy, using transmission electron microscopy and specific silver stains. It was found that the silver staining pattern of the hair shafts of black Africans was similar to that observed for Caucasians, Asians and also patients with trichorrhexis nodosa. The cuticular cells exhibited an electron dense A layer and exocuticle, and in the cortex the microfibrils forming the macrofibres were outlined by electron-dense material. This contrasts with the abnormal distribution of the cystine-rich proteins seen in trichothiodystrophy. This study is the first formal comparison of the cystine-rich proteins in the various racial groups and shows that there is no abnormality in their distribution in black African hair shafts compared to the other ethnic groups. Therefore, the excessive structural damage observed in the African hair shafts is consistent with physical trauma (resulting from grooming) rather than an inherent weakness due to any structural abnormality.

Hair and nails are often stated to have much in common in relation to their origin, anatomical structures, and common involvement in many diseases. Hair and nails are predominantly epithelial structures derived from primitive epidermis and made up of keratinous fibrils embedded in a sulfur-rich matrix. It was first noted early in the 20th century that the nail unit was comparable in several respects to a hair follicle sectioned longitudinally and laid on on its side. The epithelial components of hair follicle and nail apparatus are differentiated epidermal structures that may be involved jointly in several ways as congenital and hereditary anomalies and acquired conditions such as alopecia areata, lichen planus, iatrogenic causes, and fungal infection. Multielemental characterization of human hair and nails shows that even after sample washing, many elements are enriched in the surface of the nails.

Background: Pili annulati is an inherited hair shaft abnormality with a wide range of clinical expression., Objective: We have examined closely three kindreds to reveal levels and character of expression of the phenotype and supplement current literature on the threshold for detection and aspects of hair shaft fragility., Patients and Methods: Eleven cases of pili annulati from three families were included in a clinical and morphological study. All cases were assessed clinically and by light and scanning electron microscopy (SEM) of hair shafts. In addition, transmission electron microscopy (TEM) (four patients) and amino acid analysis (three patients) were undertaken on clinically overt cases. Results Examination by light microscopy with a fluid mountant was more sensitive than clinical examination, increasing the detection rate by 120%. Microscopic examination revealed that the characteristic periodic bands become less frequent distally in the hair shaft. Microscopic features of weathering were found in two cases, adding pili annulati to the list of structural hair shaft dystrophies that may weaken hair and dispose to weathering. Amino acid analysis of the hair of three patients with pili annulati showed elevated lysine and decreased cystine content compared to 12 normal controls, consistent with the reduced threshold for weathering., Conclusion: Careful light microscopy with fluid-mounted hair is needed to detect subjects mildly affected by pili annulati. Expression of the phenotype varies widely between individuals, between hairs and within hairs of the same individual, where ageing of the hair diminishes detectable features.

A 74-year-old woman presented with an 18-month history of broken vertex scalp hairs as a consequence of chronic rubbing. Light microscopy of the 1-2 cm hairs demonstrated distal brush-like splitting. Education and behavioural therapy were instituted. After 4 months of reduced rubbing of the vertex scalp hairs, the hairs re-grew with no evidence of persistent hair shaft abnormality.

Background: Pili annulati is a rare autosomal dominant inherited hair shaft abnormality in which clinical examination reveals alternating light and dark bands leading to a shiny appearance of the hair. The clinically light bands are the abnormal areas due to cavities within the cortex. The pathogenesis remains unknown., Objectives: To investigate the expression of the basement membrane zone (BMZ) components in pili annulati hair follicles of the scalp., Methods: Transmission electron microscopy (TEM) was carried out on scalp sections of six individuals with pili annulati and six controls. Longitudinal sections of scalp tissues from four individuals with pili annulati and six normal controls were studied by immunohistochemistry with a panel of monoclonal antibodies to the following BMZ components: alpha(6)beta(4) integrin, laminin 5, LH39 antigen, laminin 1, collagen IV and collagen VII., Results: Using TEM, pili annulati scalp specimens exhibited a reduplicated lamina densa in the region of the root bulb in comparison with the single thin electron-dense band in controls. Using immunohistochemistry, there was a wavy BMZ in pili annulati follicles with antibodies to components of the lamina lucida, lamina densa and anchoring fibrils, whereas the BMZ in control hair follicles was as a smooth linear band. The expression of the hemidesmosome-associated alpha(6)beta(4) integrin was linear in both pili annulati and control hair follicles., Conclusions: Our results suggest that the genetic defect may be a mutation in proteins involved in signalling and regulation of formation and degradation of the lamina densa and sublamina densa region resulting in abnormal assembly or remodelling of the BMZ.

Background: Hypertrichosis has been reported more frequently in females than in males who use minoxidil topical solution (MTS) for the treatment of androgenetic alopecia (AGA). This article examines the occurrence of MTS-induced hypertrichosis in females., Methods: Data from placebo-controlled clinical trials in females (up to 5% MTS) were analysed based on spontaneous reports of hypertrichosis/facial hair and investigators' inquiries (solicited) about the presence of any new hair growth on body parts other than the scalp. A postmarketing drug surveillance database for MTS was also examined for reports of hypertrichosis/facial hair., Results: In the clinical trials involving a total of 1333 females, spontaneous reports of hypertrichosis/facial hair were noted for 50 (4%) females in a dose-related pattern of response (5% MTS > 2% MTS > placebo). Nine females (seven and two in the 5% MTS and 2% MTS groups, respectively) discontinued treatment because of hypertrichosis/facial hair. Solicited reports of excessive hair growth (primarily facial) also showed a dose-related pattern of response. Post-marketing data showed a lower occurrence (0.5%) of hypertrichosis/facial hair than in the clinical trials. Of interest, in one clinical trial, 27% of the females enrolled (MTS and placebo treated) had facial hair growth reported at baseline., Conclusions: Females with some hirsutism are particularly prone to seek treatment for AGA, and this may explain the high occurrence of hypertrichosis/facial hair found in the MTS clinical trials. Furthermore, some demographic groups of females are prone to develop facial hair and the problem of unwanted facial hair growth seems to be underestimated. Some females may have hair follicles that are very sensitive to MTS and should use the lowest strength of MTS (2%) to help avoid unwanted hair growth. The hypertrichotic effect of MTS on other sites than the scalp, including the face, is reversible and does not always require discontinuation of therapy.

For decades, scientists and clinicians have examined methods of measuring scalp hair growth. With the development of drugs that stem or even reverse the miniaturization of androgenetic alopecia, there has been a greater need for reliable, economical and minimally invasive means of measuring hair growth and, specifically, response to therapy. We review the various methods of measurement described to date, their limitations and value to the clinician. In our opinion, the potential of computer-assisted technology in this field is yet to be maximized and the currently available tools are less than ideal. The most valuable means of measurement at the present time are global photography and phototrichogram-based techniques (with digital image analysis) such as the 'TrichoScan'. Subjective scoring systems are also of value in the overall assessment of response to therapy and these are under-utilized and merit further refinement.

Three cases of androgen-dependent disease in females with myotonic dystrophy are described. Serum androgens in individuals affected by myotonic dystrophy are known to be lower on average than in normal controls. Despite this these three females developed diseases that are androgen dependent, including acne, hidradenitis suppurativa, androgenetic alopecia and keratosis pilaris. These cases support the hypothesis that the peripheral response to androgens rather than absolute circulating levels of androgens is important in androgen-dependent conditions.

Hirsuties is an androgen-dependent differentiation and growth of hair in females in the same pattern and sequence as that which develops in the normal postpubertal male, but of less quantity and varying in severity. The clinical diagnosis implies underlying pathology and necessitates systematic consideration. The assessment must be adequate to distinguish between causes that are "dangerous" and those that are relatively trivial to life and health, and to determine whether the condition has consequences for well-being over the short term or may incur some significant health risks over the long term. The physiologic mechanisms for androgenic activity may be considered in three stages: (1) the production of androgens by the ovaries and adrenal glands; (2) their transport in the blood on carrier proteins, principally SHBG (sex hormone-binding globulin); and (3) their intracellular modification and binding to the androgen receptor. Causes may include polycystic ovary syndrome, congenital adrenal hyperplasia, androgen-secreting tumors, Cushing's syndrome, hyperprolactinemia, and menopause. There is a genuine need for accurate anthropologic and racial data in relation to female hair patterns.

We report two cases of keratosis follicularis spinulosa decalvans in a Caucasian family involving a 28-year-old woman and her mother. This is an unusual family in that no male relatives are similarly affected. Secondly, both patients have no significant eye changes but quite extensive scarring alopecia. To the best of our knowledge this is the second reported family in the UK.

Onychomycosis is common, affecting approximately 5% of the population, and is the most resistant form of superficial fungal infection. Dermatologists often view the nail apparatus in static terms and unfortunately give little consideration to the functional aspects of the digit. In the case of toenails, it is important to consider the toes and foot as a closely integrated functional unit. It is essential that in any case of onychomycosis or onychodystrophy that, as clinicians, we have an understanding of foot dynamics, of structure/function relationships and of the implications of orthopaedic/podiatric factors when evaluating cases of nail dystrophy. When confronted with cases of possible onychomycosis, we must adopt a systematic and sometimes multidisciplinary approach in the evaluation and management of these patients to improve patient outcomes.

Certain scalp hair shafts from 2 of 10 cases of pili annulati examined by scanning electron microscopy exhibited an unusual weathering pattern. The majority of affected hair shafts showed minor surface abnormalities at regular intervals (nodes) associated with the underlying spaces. However, in a few examples, there was marked damage to the cuticle at the nodes exposing the underlying cortex; in severe cases there was cracking of both cuticle and cortex. These damaged nodes were also associated with trichorrhexis nodosa-like breaks of the hair shaft. This study shows that the nodes in pili annulati may have some inherent weakness that could result in breaks in the hair shaft exposed to physical trauma.

Background: The hair of normal black Africans forms a mat of tightly interwoven hair shafts. The effect of this on the structure of the hair shaft and the response to grooming is unknown., Objective: Our purpose was to use light and scanning electron microscopy (SEM) to examine the structure of Negroid-type hairs and effects of combing in black African volunteers., Methods: Hair samples were collected, by combing, from Africans and compared with those from Caucasian and Asian volunteers. The volunteers had never used chemical treatments. Their hair had not been cut for at least 1 year and grooming had been limited to shampooing, drying, and combing., Results: More than 2000 hairs in 12 African volunteers were examined by light microscopy. The hairs appear as a tight coiled springlike structure. Many shafts exhibited knots (10%-16% vs 0.15%) and appear broken compared with hair shafts from other ethnic groups. SEM of African hairs showed features consistent with repeated breaks of the shaft. Examination of hairs in situ showed interlocking of hair shafts., Conclusion: These observations provide an understanding of the physical nature of, and effect of combing on, black African hair.

The scientific literature is replete with reports extolling the virtues of curettage and electrosurgery in the treatment of skin disease. Published cure rates for selected skin cancers consistently equal those for other treatment modalities, including scalpel excision. Despite this, curettage is often overlooked as a first line treatment for skin cancer. We review the evidence-based literature for patient selection criteria and curettage and electrosurgery techniques.

Differentiation within the nail unit was examined using a range of antikeratin monoclonal antibodies including the recently described antibody LHTric-1, specific to the acidic hair-type keratin Ha1. Keratinocytes of the nail matrix, nail bed and the digit pulp were characterized by different patterns of keratin expression. Nail matrix was the sole site of expression of Ha1, which colocalized in suprabasal matrix epidermis with epidermal keratins K1 and K10. Small amounts of K17 were found at the apex of the matrix in some cases. K6 and K16 were found where the epidermal surface folds forwards to become the ventral aspect of the proximal nail fold. The nail bed was distinguished by the absence of hair-type keratin Ha1 and the absence of markers of cornified epidermis and mucosal differentiation K1/K10 and K4/K13, respectively, while K6, K16 and K17 were detected. The basal keratin conformation marker, LH6, was expressed suprabasally throughout the nail bed. This complement of keratins exists in the nail bed in the absence of notable proliferative activity, and suggests a state of minimally developed differentiation which may be afforded by the physical or biological properties of the overlying nail. Keratins, K6, K16 and K17 were all found in the digit pulp in limited amounts, possibly in association with the epidermal component of the eccrine duct. The simple epithelial keratins, K7, K8 and K18, were found in small amounts in the specimens from younger individuals, mainly in epibasal cells of the apex of the matrix and in putative Merkel cells.

In this review, the current state of knowledge concerning nail melanoma is summarized. The pathogenesis, histological findings, clinical presentation, treatment and prognosis of this rare form of cutaneous melanoma are discussed. Important clinical clues to the early diagnosis of nail melanoma are highlighted and recommendations to improve the management of patients are suggested.

Netherton's syndrome is a rare autosomal recessive condition with variable expression. It comprises an ichthyosiform dermatitis and erythroderma of variable intensity and manifestations, associated with hair abnormalities. The pathognomonic finding (required for diagnosis) is that of trichorrhexis invaginata identified by light and scanning electron microscopic examination of hair shafts. This may be difficult to establish because the hair is sparse and not all hairs exhibit abnormalities. In one patient, cutaneous and hair problems had existed since infancy, and despite repeated examination of scalp hairs, the definitive diagnosis was made only by examining eyebrow hairs at the age of 30 years. We subsequently compared the number of diagnostic lesions found on scalp and eyebrow hairs from two other patients with previously diagnosed Netherton's syndrome. The density of lesions was greater in eyebrow than scalp hair, and furthermore, all eyebrow hairs had at least one lesion. It is proposed that microscopic examination, if possible, of both scalp and eyebrow hair from patients in whom Netherton's syndrome is suspected would increase the chance of a positive diagnosis.

In men who are genetically predisposed to develop androgenetic alopecia (AGA; male pattern hair loss), endogenous androgens alter scalp hair follicles, resulting in production of vellus-like, miniaturised hair, rather than cosmetically significant terminal hair. This change leads to a progressive decline in visible scalp hair density, readily perceived by the patient as thinning and, eventually, baldness. Dihydrotestosterone (DHT), a metabolite of testosterone produced by the enzyme 5alpha-reductase, has been implicated as the specific androgen in the pathogenesis of AGA. Men genetically deficient in the Type 2 isoenzyme of 5alpha-reductase do not develop AGA. Moreover, Type 2 5alpha-reductase has been detected in scalp hair follicles, and balding scalps contain increased Type 2 5alpha-reductase activity and DHT levels. Taken together, these findings provide a rationale for the use of Type 2 5alpha-reductase inhibitors in the treatment of men with AGA. Finasteride, a specific and potent inhibitor of human Type 2 5alpha-reductase, decreases the formation of DHT from testosterone. Originally developed for the treatment of men with benign prostatic hyperplasia (BPH) as a 5 mg tablet, finasteride was subsequently evaluated as a treatment for AGA. Clinical studies in balding men demonstrated that finasteride reduced scalp DHT levels and improved hair growth, confirming the role of DHT in the pathophysiology of AGA. Dose-ranging studies established the optimal dose of 1 mg/day for the treatment of men with this disorder. Large, multicentre studies established the safety and efficacy of finasteride 1 mg, leading to marketing of Propecia (finasteride 1 mg) as a new treatment for men with AGA.

In a series of 18 patients with folliculitis decalvans attending the Oxford hair clinic, eight were found to have areas of tufted folliculitis either at presentation or follow-up. There was no difference between these two groups in their presentation, clinical course, growth of causative organism (Staphylococcus aureus) or investigations including histology. We suggest that these two entities form part of a spectrum of a single disease. We performed lymphocyte staining on affected scalp biopsies, including CD4: CD8 and T-cell/B-cell ratios, but found no evidence of local immune suppression or failure which would explain the abnormal host response to a common pathogen in this rare condition. We introduced a new treatment regimen for these patients, oral rifampicin and oral clindamycin together for 10 weeks. Ten of the 18 patients have responded well with no evidence of recurrence 2-22 months after one course of treatment, and 15 of the 18 responded after two or three courses.

Nail apparatus melanoma (or subungual melanoma) is rare and accounts for only 1.4% of all cutaneous melanomas in the United Kingdom. We report the use of fixed-tissue Mohs micrographic surgery to treat a biopsy-proven Clark level I in situ nail apparatus melanoma, presenting with diffuse longitudinal melanonychia.

We report two patients, mother and daughter, with Erythrokeratoderma variabilis (EV). This rare genodermatosis is characterized by the presence of two components: migratory erythema and fixed hyperkeratosis. Our patients experienced symptomatic relief of pruritus associated with erythema with the use of an oral, low-sedating H1-antihistamine. Revision of the literature in order to allocate the frequency of pruritus in EV and discussion of this association will follow.

Our population-based study establishes epidemiological data on age-specific incidence rates, clinical presentation, Breslow microstaging, treatment and survival of nail apparatus melanoma (NAM) patients in England. Four cancer registries, covering a population of 10.6 million, recorded 105 cases of NAM during the period 1984-93. During the same decade there was a total of 7585 patients with cutaneous melanoma and NAM represents 1.4% of all cutaneous melanoma. The incidence rate of NAM in English patients is 0.1 per 100,000 of the population per annum. Amelanotic melanoma was the clinical presentation in 24 of our NAM cases. The overall prognosis is poor with an observed 5 year survival of only 51%. Patients with NAM less than 2.5 mm Breslow depth have a 5 year survival of 88% and are twice as likely to survive compared with those with tumours greater or equal to 2.5 mm in thickness (P < 0. 05). NAM patients are best managed by a multidisciplinary team approach in a few key skin cancer centres.

Bowen's disease has a particular predilection for the lower leg, especially in women. A review of the literature for treating Bowen's disease is presented and the problems associated with treating the lower leg emphasized. Evidence for the various treatment modalities used to treat Bowen's disease largely comes from studies that lack good methodology in terms of standardized techniques, patient controls and adequate follow-up. In particular the widely accepted recommendation for excision is not supported by evidence that this treatment is superior to other modalities. The choice of treatment for Bowen's disease should take into account the patient's general condition, the site and size of the lesion.

Squamous cell carcinoma of the nail bed is a relatively uncommon tumour that may be diagnosed only after considerable delay. The first case presented is a 79-year-old man with a history of discomfort and discoloration affecting the right thumbnail of 3 years duration. The second case is a 70-year-old man who presented with a recurrent, offensive discharge from beneath the left thumbnail of 40 years duration. Clinical examination of the affected digits revealed minor nail abnormalities. The presence of tumour was fully apparent only after removal of the nail plate and inspection and biopsy of the nail bed. The cases demonstrate that subungual squamous cell carcinoma may present with prolonged symptoms and a deceptively benign appearance. The importance of consideration of the possibility of malignancy, removal of the nail plate for inspection of the nail bed and appropriate biopsy is emphasized.

Dimethylether/propane is an organic substance used as a refrigerant in a new cryodelivery system marketed for the treatment of warts. The objective was first to determine the temperatures achieved by this delivery system, both at the end of the applicator and in the tissues and, second, to compare with liquid nitrogen delivered via standard cryospray equipment (CryAC). Temperature probes were used to measure temperature 1 mm below the epidermis of pig trotters after freezing with the two delivery systems for 20 and 40 s. After freezing with dimethylether/propane, results showed tissue temperatures were 3 degrees C at 20 s and 0 degree C at 40 s. Freezing with liquid nitrogen achieved -20 degrees C at 20 s and -57 degrees C at 40 s. It was concluded that dimethylether/propane does not achieve tissue temperatures below 0 degree C and is not recommended in the use of malignant or premalignant lesions.

Lentigo maligna (LM) is the in situ phase of lentigo maligna melanoma (LMM) and, if left untreated, 30-50% of cases will progress to LMM, which is now thought to behave as aggressively as any other melanoma. Literature on the of treatment of LM including conventional surgery, micrographic Mohs surgery, cryosurgery, radiotherapy, electrodesiccation and curettage. 5-fluorouracil (5-FU), azelaic acid, retinoic acid and lasers are reviewed. It is concluded that micrographic Mohs surgery has the lowest recurrence rates and that conventional surgery, cryosurgery and radiotherapy all have recurrence rates in the order of 7-10%. Therefore, on the basis of the current literature available, all three of these methods could be recommended as primary treatment of LM. It is extremely important when choosing one of the above treatments that the physician is adequately trained in the appropriate technique and understands the limitation of the method used and the need for close follow up of the patient.