Case
Severe Itchy/Stingy Scalp

Age: 55
Sex: Female
Race: Hispanic

History
History of present illness:
Hair loss started approximately 9 yrs. ago, but is not dry--looks normal. Have noticed a small area where hair is missing and no hair folicals are there. Hair falls out by itself and texture has become frizzy and dry and scarce.

Medical History:
Have IBS and nodules in throat--have thyroid problem, but controlled with medication. Urinate frequently (at least 6 times in one morning), but tests are normal

Past surgical history:
None

Allergies:
Pennecillin, Sulfa, Prednizone, Flygyl

Medications:
Levrothyroxin, Activeella 1-0.5

Vitamins: Veggie Caps, Calcium, Vitamin D (Sun Harvest) and Anxiety Control (Whole Foods)

Family history:
Brother died of Renal Cancer at age 41, Grandmother had Diabetes, Brother has Diabetes (but eating habits are bad and is overweight).

Social history:
Work 8 hrs., take care of home & own gardening, intermitently see grandchild (once at month), exercise every other day including do physical therapy routine, stay at home primarily and take elderly mother to eat at least 2-3 times a month and grocery shopping once-in-awhile.


Physical Exam
General:
Good

Temperature:
98.6

Heart rate:
75

Blood pressure:
103/66 as of 7/27/09

Respiratory rate:
Good

Oxygen saturation:
Not tested , but probably fine

Head, ears, eyes, nose & throat:
Have thyroid problem, but controlled with medication, have noticed a little bit of dizzyness for at least 2 weeks now, which I think might be due to ears

Neck:
Have small nodules in throat, which is monitored through periodic soundagrams and treated through Levrothyroxin.

Chest:
Fine

Cardiovascular:
Fine

Abdomen:
Have IBS--stomach swells once-in-a-while

GU:
Don't know what this stands for

Rectal:
Fine per Colonoscopy in 2007

Skin:
Normal and scalp is normal as well--not dry and not oily

Laboratories:
Just tested for Kidney's and everything came out fine

Other:
Have hair dyed at hair salon every 5 weeks--can feel itch & stinging (sting feels relief for itch) while color is on. Shampoo's also cause itch, so I changed to wholesome shampoo from Sun Harvest (more natural). All make head itch. I only blow dry with cool hair in that area, but let it finish drying by itself in the mornings. I never sleep with my hair wet as I wash it every other morning. Becoming unbearable.

Problems:
Itch has intensified over 3 months now; however itch has been there moderately for at least 2 yrs. Intensity comes and goes throughout the day and night.
Need help desperately and could use some expert advice, as my Dermatologist has no idea.

Assessment:
Dermatologist found nothing wrong. He says that the doctors in his office said several women patients complained of the same symptoms and they attributed to perhaps Menapause. I started Menaupause at the age of 40.

Plan of treatment:
Was given Loprox 1% Shampoo to apply every other day for 4 weeks. I also purchased tea tree oil from Sun Harvest and use it before the shampoo.

Results of treatment:
Have used Loprox 4 times now, but feel no relief. Upon applicaiton of tree tea oil (used twice), feels cool on scalp, but after rinse and twel dry, itch is still there and feels unbearable. I need help desperately--Any expert advice please???




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