Telogen effluvium

What is telogen effluvium?

Telogen effluvium is rapid hair loss that is caused by stress or a change to your body. It is a temporary condition and the hair growth usually recovers.

Symptoms of telogen effluvium

The main symptoms of telogen effluvium are:

• Increased hair loss from the scalp. This is more than normal and most noticeable when you wash your hair.

• Generalised thinning of hair on the scalp.

• Dry hair that falls out easily.

However, your scalp and the remaining hair will look healthy. You will not have patches of hair loss (bald patches) but rather a generalised thinning.

There are images of telogen effluvium in the Further reading references below.

Who develops telogen effluvium?

Risk factors for telogen effluvium include:

• Female or assigned female at birth (AFAB).

• Aged between 30 and 60.

• Having major surgery.

• Childbirth and postpartum.

• Psychological stress.

• Hyperthyroidism.

• Hypothyroidism.

• Medications, including retinoids, beta-blockers, calcium channel blockers, antidepressants and nonsteroidal anti-inflammatory drugs (NSAIDs).

Telogen effluvium usually occurs about 1-3 months after a major stress to the body. The most common time it occurs is in women about 1-3 months after childbirth. Other times include 1-3 months after a major operation, accident, or illness.

Why does telogen effluvium occur?

A major stressful event such as childbirth or major surgery can interrupt and stop the growth of some hairs. It tends to affect older hairs which are brought to an end of their life cycle earlier than the usual three years or so. Many more hairs than usual are then ready to fall out.

Other events that might trigger telogen effluvium (TE) include sudden feverish illness; severe infection; major surgery; severe trauma; postpartum hormonal changes; hypothyroidism; crash dieting; low protein intake; heavy metals; and iron deficiency.

Suddenly stopping oestrogen-containing medications (such as the combined hormonal contraceptive pill or hormone replacement therapy can also cause TE. Many other medications have been linked to telogen effluvium, but some of the most common are beta-blockers; retinoids, including excess vitamin A (often used for skin problems); anticoagulants (often called blood thinners); propylthiouracil (used for thyroid conditions; carbamazepine (used for seizures); and immunizations.

As many as 1 in 3 cases of telogen effluvium have no obvious cause.

The normal life cycle of scalp hair

Hair is made in tiny pouches in the skin, called hair follicles. Each scalp hair has a normal life cycle. Most scalp hairs last about three years and grow about 1 cm a month. After a period of time (about three years), each hair on the scalp comes to the end of its life and falls out. The hair follicle rests for a short while. It then starts to make a new hair.

All the hairs on the scalp are at different stages in their life cycle.

Each follicle produces a number of hairs during a lifetime. There are three phases:

• Anagen or growth phase on the scalp lasts between three and five years and the hair grows at approximately 1 cm a month. The duration of the anagen phase varies from person to person and it determines how long hair will grow if not cut. Usually about 85% is in anagen phase.

• Catagen phase follows the anagen phase and is an involutional stage that lasts around two weeks.

• Telogen (or dormant) phase lasts about three months. The hair remains in the follicle but does not grow.

At the end of the telogen phase the follicle starts production of new anagen hair.

At any one time about 1 in 100 scalp hairs are at the end of their life ready to fall out. This is why you will commonly find a few hairs on your shoulders and some hairs fall out each time you wash your hair. During telogen effluvium you might lose up to 300 hairs.

How is telogen effluvium diagnosed?

Typically, obtaining a detailed history and performing a thorough physical examination are sufficient for diagnosing telogen effluvium. The history and physical examination is grossly normal, as it is difficult for the casual observer to appreciate the volume of hair loss.

Comparing the patient's current appearance with old pictures can be beneficial. If the patient presents during the acute shedding, a gentle pull test results in the removal of at least four hairs with each pull. However, if the patient presents after the acute shedding has passed, the pull test may yield normal results.

A thorough examination of the scalp may reveal an increased percentage of short anagen hairs growing close to the scalp, and no scarring should be evident.

Because nail and hair growth are under the same influences, a problem with hair growth is often mirrored in the nails by a groove across them. This groove will coincide with the time of the shock to the system. It is called a Beau line. The time of the shock can be estimated from the fact that a fingernail takes 5 months to grow from the base (where the cuticle is) to the free edge. So if the groove in the nail is halfway down the nail, the shock must have been two and a half months ago.

If a biopsy is performed during the acute shedding phase (when the pull test is positive), it can confirm an increase in the percentage of telogen hairs.

Testing for underlying hormonal conditions, such as hypothyroidism, chronic metabolic illnesses, or iron deficiency is recommended if there are concerns about these conditions following the history and examination.

What is the treatment for telogen effluvium?

No treatment is available or required in most cases. Once the stressful event has passed, your hair thickness will usually return to normal within a few months.

Topical minoxidil might be helpful but it has not been proven to promote hair recovery in telogen effluvium. Patients who wish to take an active role in their treatment may choose to try topical minoxidil. Recent trials have proven that oral minoxidil can be an effective and well-tolerated treatment alternative for healthy patients who have difficulty using topical formulations.

Rarely, you may have telogen effluvium caused by zinc deficiency or iron deficiency and taking appropriate supplements cures the problem.

Can telogen effluvium be prevented?

This is difficult as there are so many different causes and shocks to the system can be hard to predict and avoid. Eating a balanced diet (so avoiding deficiencies and needing to take supplements) is a good start without obvious drawbacks. Looking after your mental health and dealing with stresses, or asking for help are also important.

What is the outlook (prognosis)?

Good recovery of hair density usually occurs in acute telogen effluvium. Most often cosmetic changes are very difficult to observe. A good cosmetic outcome is also expected in chronic telogen effluvium, even if the hair shedding continues for some time.

Telogen effluvium has the potential to have a significant psychological impact on individuals affected by the disease. If appearance has been altered counselling may be required.