Management of BNS requires the correction of the precipitating cause by hydration of the nail blade, cuticle, and proximal nail folds, preferably under occlusion. Supplementation with biotin is considered highly effective by many researchers.54,55 In a retrospective study, the use of biotin for 6 months improved BNS in 63% (22/35) of patients.56 Recommended doses generally are more than 2.5 mg daily.57 The use of 10% urea in nail polish once or twice daily showed that both regimens improved the morphology, consistency, and reflectiveness of the nail plate.52
The use of nail polish containing hydroxypropyl chitosan, Equisetum arvense extract, and methylsulfonylmethane has been reported as a treatment of dystrophic and fragile fingernails. The treatment was evaluated in patients with nail psoriasis and it was shown to be effective in decreasing dystrophy.58
Although women are affected twice as frequently as men,51 there are no known studies comparing the prevalence of BNS in premenopausal versus menopausal women, despite the fact that the ratio of women to men affected has been shown to increase with age.51,52 In our clinical practice, BNS predominates among menopausal women. We believe that low estrogen levels may lead to dehydration of the nail plate.
Frontal fibrosing alopecia has a tendency to affect menopausal women.59 Frontal fibrosing alopecia is a slow, progressive, lymphocytic cicatricial alopecia that produces symmetrical frontal or temporal recession but rarely affects other areas of the scalp. It often is associated with nonscarring alopecia of body hair or eyebrows. The cicatricial area is atrophic, pale, and surrounded by hyperpigmented skin due to long-term sun damage.60,61
Many investigators believe it is a variant of lichen planopilaris.62,63 Others suggest the possibility that hormonal changes characteristic of perimenopause contribute to triggering the disease. Some cases show a partial response to finasteride or dutasteride.64 Furthermore, the lymphocytic inflammatory component of the disorder has been treated with immunomodulators, topical and intralesional corticosteroids, and hydroxychloroquine.60,63
Telogen effluvium (TE) is the premature transformation of hair from the anagen phase to the telogen phase. Considered a symptom of an underlying condition (eg, endocrine, nutritional, and autoimmune disorders) rather than a full diagnosis in itself,65 TE is characterized by diffuse hair loss confirmed by a pull test in which more than 5 hairs are removed from the scalp on tugging a section of 25 to 50 hairs.66 If there is concurrent TE in women with androgenetic alopecia, more severe hair loss has been reported.24,66 There may be concerns of dysesthesia of the scalp (trichodynia), especially in patients with emotional stress.66
Most often diagnosed in women, TE in its acute form is even more common in menopausal women and lasts less than 6 months.24 The acute form of TE is secondary to hemorrhage, high fever, surgery, drug use, systemic diseases, diet, or great psychological stress and typically occurs 1 to 3 months after the primary event.24,66 The most common cause of iron deficiency at menopausal transition is malabsorption or chronic gastrointestinal bleeding. Ferritin levels below 40 µg/L are associated withhair loss with a 98% specificity and sensitivity.24 Low serum levels of vitamin B12 or VD also are considered important factors.24,65,66
Chronic TE (ie, lasting more than 6 months) predominantly occurs in women aged 40 to 60 years, and its onset is abrupt. Chronic TE is considered a diagnosis of exclusion.24 In 30% of cases of chronic diffuse hair loss lasting longer than 6 months, the cause is unknown.67 The pathogenesis is poorly understood, though it is assumed to result from a reduced duration of the anagen growth phase in the absence of shrinking hair follicles.37,68
Patient education is the most important aspect of TE management. The aim of treatment is to reduce hair loss and correct the precipitating factors. Even if the underlying cause is corrected, hair loss may continue for up to 6 months with the desired cosmetic regrowth occurring after only 12 to 18 months.37,65 In acute secondary TE, the course of the disease is self-limited, and correction of the causal factor is sufficient. In chronic diffuse loss, identification of causal factors is more difficult and treatment involves adequate nutrition (ie, at least 1200 calories daily including 9.8 mg/kg body weight of protein) and multivitamin supplementation, minoxidil, and even antiandrogen medications.37,65-67
Trichotillomania is the compulsive behavior of plucking strands of hair and is considered to be a poor adaptive response to stress. Although trichotillomania most commonly occurs in children, adolescents, and young adults, in older adults it is more often associated with psychopathology and is markedly more common in women.69 The condition usually is refractory to treatment, and although the scalp usually is the primary focus of the behavior, eventually patients may pluck body hair. Menopausal women also may present with trichoteiromania in which hair loss is secondary to repeated friction that has fractured the hair shaft; this condition often is associated with scalp dysesthesia.24 Trichotillomania is considered an obsessive-compulsive disorder, whereas trichoteiromania needs further investigation because it can occur secondary to many psychiatric disorders. The specific psychotherapeutic and pharmacologic treatments likely will depend on the underlying cause of the disease.70
