Mens health hair and skin problems by csgirla


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                  CPD                                  (

Men’s health: hair and skin problems
In this final article in our men’s health series, Christine Clark looks at some non-life threatening but, none the less, serious men’s health problems
    here are a number of common skin and                   licensed for the treatment of alopecia

T   hair problems for which men seek advice
    from pharmacists.These include hair loss,
shaving problems, acne and fungal infections.
                                                           androgenetica in men aged 18 to 65 years; the
                                                           lower strength can be used for hair loss in
                                                               Applied twice daily, minoxidil is believed
Male pattern baldness                                      to work by increasing blood flow (by vasodi-
Male pattern baldness (alopecia androgenet-                lation) to the remaining hair follicles. Each
ica) is the most common form of hair loss in               pack contains the lotion, a metering device
men. It usually develops gradually and typi-               and three different applicators (pump spray,
cally involves the appearance of a bald spot on            extended spray tip and rub on applicators) to
the crown of the scalp, accompanied by hair                suit individual needs. It can take at least two
thinning at the temples. Male pattern baldness             months before an effect is noticed and,
can start at any time, but most men first be-              unfortunately, minoxidil does not work for
come aware of it as they approach their thir-              everyone. It is estimated that about one third
ties. It is estimated that two-thirds of all men           of men who use it will get good hair growth,
will be affected by male pattern baldness.This             one third will get a fine, downy regrowth and
occurs most commonly in Caucasians, fol-                   one third will get little or no effect. If there     Identify knowledge gaps
lowed by Afro-Caribbeans. Male pattern                     has been no response after 12 months’                1. What is balanitis?
baldness is hereditary but, curiously, maternal            treatment it is unlikely that further treatment      2. How is sycosis barbae treated?
genes appear to have the stronger influence.               will produce any effect. Moreover, minoxidil         3. What are the options for men with hair loss?
    Male pattern baldness is androgen-                     is only effective if it is used regularly. Once
dependent and may be associated with over-                 stopped, any regrowth will be lost.                  Before reading on, think about how this article
sensitivity of hair follicles to dihydrotestos-                The summary of product characteristics           may help you to do your job better. The Royal
terone (DHT). Men with a genetic deficiency                states that topical minoxidil should not be          Pharmaceutical Society’s areas of competence
of type-II 5α-reductase (the enzyme that                   used by men who have hypertension, those             for pharmacists are listed in “Plan and record”,
converts testosterone to DHT) do not                       with scalp lesions (eg, sunburn or psoriasis)        (available at: This
develop male pattern baldness. One study has               that could lead to increased absorption of           article relates to “common disease states and
shown a link between smoking and hair loss.                minoxidil or those who have shaved scalps or         their drug therapies” (see appendix 4 of “Plan
    Other types of hair loss can be caused by              who are using other topical scalp treatments.        and record”).
serious systemic illness, chemotherapy, scalp              Although there is normally little absorption
infections (eg, ringworm), stress and thyroid              of topical minoxidil, users should be
disease. It is important to establish the correct          reminded that if they experience dizziness,        Shaving problems
diagnosis because some types of hair loss can              palpitations, chest pain or sudden weight          Red, raised bumps and ingrown hairs, irrita-
be reversed.                                               gain, they should stop using minoxidil and         tion or rashes in the beard area can all be
    It is now recognised that male pattern                 seek medical advice. The topical product           problems associated with shaving. These are
baldness can cause considerable psychological              contains alcohol and the mist may burn the         more common in men who have curly facial
distress and have a significant impact on qual-            face or eyes.                                      hair — up to 80 per cent of Afro-Caribbean
ity of life. Consequently, some men with male                                                                 men suffer from shaving problems.
pattern baldness are easy targets for charlatans           Finasteride Finasteride, an inhibitor of type-        Barber’s rash (sycosis barbae, folliculitis) is
and miracle-cure merchants. Referral to a                  II 5α-reductase, is licensed for the treatment     caused when the hair follicles become
qualified trichologist (see Institute of                   of male pattern baldness. Currently it is only     infected with the commensal organism
Trichologists website:              available on a private prescription.The dose is    Staphylococcus aureus, which is commonly
uk) can be helpful but this service is not avail-          1mg daily (Propecia).                              found in the nasal passages. Infection leads to
able on the NHS. Nothing can prevent male                     Hair follicles contain type-II 5α−reductase.    redness, itching and small, pus-filled blisters.
pattern baldness and only general measures                 In men with male pattern baldness, the scalp          Razor bumps (shaving rash, pseudofolli-
such as good hair care, avoidance of unneces-              contains shrunken hair follicles and increased     culitis barbae) occur when the hair curls and
sary trauma to the hair or scalp and a bal-                amounts of DHT. Finasteride decreases scalp        grows back into the skin. The follicle
anced diet can be recommended.Advice from                  and serum DHT concentrations in these men          becomes inflamed and susceptibility to infec-
a hair stylist can also help (eg, a short haircut          and reverses the balding process. Daily            tion is increased (leading to full-blown folli-
draws less attention to thinning or receding               treatment for three to six months is usually       culitis.) Ingrowing hairs occur spontaneously
hair than hair combed over a bald spot).                   needed before the effects are seen.                in individuals with curly hair but can also
                                                              Reported side effects are rare but include      occur in others when the hair is cut too short
Treatment Effective treatments for baldness                impotence, reduced sex drive and reduced           (below the skin surface).
are drug treatment (using the antihyperten-                semen volume. All are reversible on discon-
sive minoxidil or the anti-androgen finas-                 tinuation of treatment. Finasteride also           Treatment and prevention Folliculitis is
teride) or hair transplants.                               reduces serum prostate-specific antigen (PSA)      treated with systemic antibiotics (eg, flu-
                                                           levels and this should be taken into account if    cloxacillin). Pseudofolliculitis can be treated
Minoxidil Topical minoxidil is available in                a PSA assay is required during treatment with      by adopting a good shaving technique. If the
two strengths (2 or 5 per cent). Both are                  Propecia.                                          skin is irritated a period of not shaving can
                                                              Men who are already taking finasteride for      also help. Occasionally, a topical antibiotic is
        Christine Clark, PhD, FRPharmS, is a               prostatic hyperplasia (Proscar) should not also    recommended (eg, clindamycin). In the long
        principal research fellow in clinical              take Propecia. The effects of oral finasteride     term, good skin care and a good shaving
        therapeutics (part-time) at Bradford               and topical minoxidil used together have not       technique usually solve the problem (see
        University School of Pharmacy                      been evaluated.                                    Panel 1, p643).

642   The Pharmaceutical Journal (Vol 272) 00 Month 2004                                                                        
Acne vulgaris                                                                                                                                     ing, socks and underwear should be washed
Some 70 per cent of adolescents develop acne                                                                                                      on a hot wash cycle.There is no need to avoid
and men appear to be affected more severely                                                                                                       sports but sports clothes should be washed
than women. Incidence peaks at 18 years of                                                                                                        regularly and towels should not be shared.

                                                                                                           Mike Wyndham Medical Picture Library
age, but older adults can be affected.
    Acne vulgaris is an inflammatory condi-                                                                                                       Candidal balanitis
tion affecting the sebaceous follicles of the                                                                                                     Balanitis is inflammation of the head of the
face, chest and back. Increased androgen levels                                                                                                   penis. Although it has many causes, infection
at puberty stimulate sebum secretion and fol-                                                                                                     with the yeast Candida albicans is the most
licular hyperkeratosis. Comedones form when                                                                                                       common.Typically, this presents as generalised
the sebaceous glands become blocked with                                                                                                          erythema of the glans or foreskin, or both
skin debris and lipid-rich sebum. These are                                                                                                       (which may have a dry glazed appearance),
readily colonised by Propionibacterium acnes and       Sycosis barbae can be prevented with a                                                     with eroded white papules and a white, foul-
pustules and inflammatory lesions develop.             good shaving technique                                                                     smelling discharge. Other symptoms include
    Mild acne involves open and closed come-                                                                                                      soreness and irritation. Candidal balanitis can
dones (whiteheads and blackheads). In more             correctly for two months before considering                                                be acquired through intercourse with an in-
severe disease, pustules and inflammatory              an alternative — treatment failures often                                                  fected partner but it can also occur in people
nodules are present. If untreated, severe              result from incorrect use or unrealistic expec-                                            with diabetes and after antibiotic treatment.
inflammatory acne can lead to permanent                tations. If correctly used benzoyl peroxide is                                             Intercourse should be avoided during treat-
scarring and severe psychosocial conse-                ineffective, prescribed treatment can be tried.                                            ment to avoid reinfection.
quences including depression, loss of self-            The three topical antibiotics licensed for acne                                                Topical imidazoles are the first line treat-
esteem and social withdrawal.                          in the UK are erythromycin, clindamycin and                                                ment for candidal balanitis. The cream or
                                                       tetracyline. First line oral antibiotics are                                               ointment should be applied twice daily for
Treatment Acne cannot be prevented. It is              oxytetracycline and tetracycline. Other treat-                                             two weeks and for at least one week after
not caused by poor hygiene or eating choco-            ments include retinoids and azelaic acid.                                                  symptoms have disappeared. A topical imida-
late or a fatty diet.The mainstay of treatment                                                                                                    zole combined with 1 per cent hydrocorti-
of mild to moderate acne is the oxidising              Fungal infections                                                                          sone may be prescribed if there is significant
agent benzoyl peroxide. This is bactericidal           Fungal infections are caused by infections                                                 inflammation and itching. Oral fluconazole is
against P acnes and has some anticomedogenic           with dermatophyte fungi or yeasts, which                                                   an option if topical treatment is ineffective.
activity. Benzoyl peroxide is available in a           thrive in warm, moist conditions.                                                          Over-the-counter packs of fluconazole
wide range of formulations and strengths                                                                                                          should only be sold for balanitis if recom-
(from 2.5 to 10 per cent). The choice of               Tinea Athlete’s foot (tinea pedis) is the most                                             mended by a doctor. Bathing with saline is
formulation depends on skin type as well as            commonly seen fungal infection. It is estimated                                            soothing and may be helpful.
personal preference. Gels and solutions have a         to affect 15 per cent of the population and                                                    Although balanitis is less common in those
drying effect, which people with oily skin             presents as itchy, macerated skin, between the                                             who have been circumcised, there are no trial
may like. In contrast, creams are moisturising         toes. Itching and inflammation can spread to                                               data on circumcision as a treatment for recur-
so may be better for dry skin. Lotions are             the skin around the toes and the sole of the foot                                          rent balanitis. For uncircumcised men, good
useful when application to large areas of skin         (known as “moccasin” distribution). Occlusive                                              personal hygiene is important to avoid infec-
is required. In general, gels, creams and lotions      footwear, warm, damp working conditions and                                                tion — the area under the foreskin should be
are preferable to washes, which have shorter           hot weather create the conditions for athlete’s                                            kept clean and dry.The consensus view is that
skin contact. Skin irritation (redness, dryness,       foot to thrive. Shared washing facilities allow                                            circumcision may benefit individuals with
and stinging) is a common side effect of               the fungus to be transmitted.                                                              recurrent infective balanitis.
benzoyl peroxide, but can be minimised by                  Fungal infection of the groin (tinea cruris,
starting with the lowest strength.                     jock itch, Dhobie itch) affects men more
    Treatment should be applied to the whole           frequently than women and is caused by the                                                   Action: practice points
of the affected area and not just the visible          same dermatophytes that cause athlete’s foot.                                                Reading is only one way to undertake CPD and the
spots (new comedones may be forming                    The skin of the upper inner thighs, pubis and                                                Society will expect to see various approaches in a
below the skin surface). It should be used             anal region is infected.The scrotum is usually                                               pharmacist’s CPD portfolio.
                                                       spared.Typically, it appears as an erythematous                                              1. Visit the Prodigy website and answer the
                                                       area with a well-defined, scaly edge.                                                            following questions:
  Panel 1: Tips for a good                                 Superficial dermatophyte infections can be                                               ■ How is acne classified in clinical trials?
  shaving technique                                    treated with topical products containing imi-                                                ■ When are oral antibiotics effective for acne?
                                                       dazoles (eg, clotrimazole) or terbinafine.                                                   ■ If a treatment appears to be working, for how
  ■ Hairs should be cut flush with the surface of      Imidazoles are fungistatic whereas terbinafine                                                   long should it be continued?
    the skin, with minimal friction and irritation     is fungicidal. Both types of product are used                                                2. Review which products can be sold for
    to the surrounding skin                            twice daily but terbinafine is effective in seven                                                candidal balanitis and read their patient
  ■ Shaving when the hairs have been wet for           days whereas up to four weeks’ treatment with                                                    information leaflets.
    five minutes (eg, at the end of a shower)          an imidazole may be required to clear an                                                     3. Brainstorm with your staff. What can you do
    means that the hair is easier to cut — wet         infection. The symptoms will be relieved                                                         to bring more men into your pharmacy?
    hair is much softer than dry hair                  before a mycological cure is achieved.
  ■ Shave in the direction of hair growth (usually         It is important to take steps to minimise
    with downward strokes)                             the possibility of reinfection. These include                                                Evaluate
  ■ Repeated strokes should be minimised —             regular washing and careful, thorough drying                                                 For your work to be presented as CPD, you need to
    this will not give the closest shave, but it       of the affected areas. An antifungal dusting                                                 evaluate your reading and any other activities.
    reduces the risk of ingrown hairs and irritation   powder can be helpful. Footwear should also                                                  Answer the following questions: What have you
  ■ Shave with the skin in a relaxed position —        be treated to prevent reinfection from residual                                              learnt? How has it added value to your practice?
    avoid stretching the skin taut                     spores. Wearing cotton socks and avoiding                                                    (Have you applied this learning or had any
  ■ Alternatively, use an electric razor that          trainers whenever possible helps to avoid con-                                               feedback?) What will you do now and how will this
    leaves the hair a little longer                    ditions favourable to dermatophytes. Because                                                 be achieved?
                                                       the fungi can survive on skin debris in cloth-                                                                                                                                    22 May 2004 The Pharmaceutical Journal (Vol 272) 643

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