1. In women with female pattern alopecia and other signs of hyperandrogenism (ie, hirsutism, moderate to severe acne, acanthosis nigricans, menstrual irregularities, and/or galactorrhea), screen for hyperandrogenemia by obtaining a free and/or total testosterone level, with or without a dehydroepiandrosterone level.

2. For premenopausal women with an abnormal hirsutism score (ie, modified Ferriman-Gallwey score of 8 or greater), assess for an elevated androgen level by obtaining a serum total testosterone level. If the level is normal in patients with moderate to severe hirsutism and/or evidence of a hyperandrogenic endocrine condition (eg, menstrual irregularities, progression despite therapy), obtain an early morning serum total testosterone level and a free testosterone level.

3. For premenopausal women with hirsutism who are not seeking fertility, prescribe combination oral contraceptives for pharmacotherapy.

4. For patients with onychomycosis, counsel that restoration of the nail to its normal state may take time. Also, counsel that clinical cure may not be possible in some cases (eg, severe onychomycosis, secondary nail disease, immunosuppression, previous nail trauma).

5. For patients with nail psoriasis, choose the treatment option based on the number of digits involved (ie, 3 or less versus more than 3) and nail matrix versus nail bed involvement.

Resources

1. Strength of Evidence: SORT C

   Source: J Am Acad Dermatol, reference 55

Website: https://www.jaad.org/article/S0190-9622(04)01058-8/fulltext

2. Strength of Evidence: SORT C

   Source: Endocrine Society, reference 126

Website: https://academic.oup.com/jcem/article/103/4/1233/4924418

3. Strength of Evidence: SORT C

   Sources: Androgen Excess and Polycystic Ovary Syndrome Society, Endocrine Society, references 109 and 126

Websites: https://academic.oup.com/humupd/article/18/2/146/618266; https://academic.oup.com/jcem/article/103/4/1233/4924418

4. Strength of Evidence: SORT C

   Source: J Am Acad Dermatol, reference 156

Website: https://www.jaad.org/article/S0190-9622(18)32187-X/fulltext

5. Strength of Evidence: SORT C

   Source: J Am Acad Dermatol, reference 166

Website: https://www.jaad.org/article/S0190-9622(19)30183-5/fulltext