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A. Tosti et al. (eds.)Hair and Scalp Treatmentshttps://doi.org/10.1007/978-3-030-21555-2_10

10. Telogen Effluvium

Brandon Burroway¹, Jacob Griggs¹, Maria Abril Martinez-Velasco² and Antonella Tosti³

(1)

Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA

(2)

National University of Mexico, Department of Onco-dermatology and Trichology Clinic, Mexico City, Mexico

(3)

Fredric Brandt Endowed Professor of Dermatology, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA

Antonella Tosti

Email: atosti@med.miami.edu

Keywords

Telogen effluviumHair lossHair sheddingHair pullPsychological impactNutritionMinoxidilEducationReassurance

Introduction

Telogen effluvium is one of the most common causes of hair loss; however, it has heterogeneous triggers. The exact number of cases is difficult to assess as many are subclinical and do not result in office visits [1]. It is important to understand that if the triggering factor is not identified, the therapy will be symptomatic instead of resolutive. Telogen effluvium has two subtypes: acute and chronic.

It appears to be more common in women, but this propensity may be due to men underreporting the disease [2]. Acute telogen effluvium results from acute transition of follicles from anagen to telogen phase [1], and it can be secondary to both internal and external insults. The effects of age on acute telogen effluvium are not entirely clear but some studies have shown evidence that elderly woman are more susceptible [2], whereas it is uncommon in children [3, 4]. Chronic telogen effluvium has a strong predilection for women aged 30–60 [5]. It does not appear to have any racial predilection.

Etiology

Possible mechanisms of telogen effluvium are listed in Table 10.1 [6].

Table 10.1

Proposed mechanisms of telogen effluvium

Mechanism	Notes
Premature anagen phase interruption	Most common type Hair shedding 2–3 months after initiation of the causative factor, due the transition from anagen through catagen and telogen with a subsequent release of telogen hairs For example, physiologic stress, fever, drugs, scalp inflammation, weight loss, smoking, and major surgeries
Excessive prolongation of the anagen phase	Hair follicles remain in prolonged anagen phase rather than cycling into telogen. When finally released from anagen phase, telogen effluvium is manifested For example, post-partum telogen effluvium and telogen effluvium occurring after the interruption of topical minoxidil or oral contraceptives
Reduced anagen phase duration	Mechanism behind telogen effluvium sometimes occurring alongside androgenetic alopecia, hypothyroidism, iron deficiency, and senescent alopecia
Delayed teloptosis	Hair follicles remain in prolonged telogen phase rather than being shed and recycled into anagen phase For example, scalp psoriasis
Premature teloptosis	Seen with drugs that promote anagen re-entry or proteolysis and rupture of cadherins Mechanism behind telogen effluvium occurring after the initiation of topical minoxidil [7] Keratolytics and retinoids are also implicated

Although many diseases and drugs are well known to cause telogen effluvium, no studies have looked at the probability that they will cause telogen effluvium. The most common factors are identified in Table 10.2 [8]. It should be noted that many cases are deemed idiopathic as the inciting factor is never identified [1].

Table 10.2

Causes of telogen effluvium

Physiologic	Postpartum
	Shedding of the newborn
	Seasonal shedding
Illness associated	Postfebrile and infections (i.e., typhoid, malaria, TB, syphilis)
Illness associated	Chronic illness (i.e., HIV)
Stress	Serious injuries
	Major surgery
	Hemorrhage
	Starvation or rapid weight loss
	Significant psychological stress
	Strenuous physical exercise
Nutritional	Malnutrition [9]
	Crash diets [10]
	Iron deficiency anemia
	Acquired zinc deficiency
	Acrodermatitis enteropathica
Drugs	Oral retinoids
	Antithyroid drugs
	Anticonvulsants
	Hypolipidemic drugs
	Heavy metals [11]
	Beta blockers
	Captopril [12]
	Amphetamines [12]
	Anticoagulants [12]
	Discontinuation of oral contraceptives [13]
	Interferon-α-2b [13]
Endocrine	Hyperthyroidism
Endocrine	Hypothyroidism
Organ dysfunction	Renal failure
Organ dysfunction	Hepatic failure
Local cause	Hair transplant [14]
	Contact dermatitis (i.e., hair dye application) [15]
	Local surgery [16]
	Inflammatory conditions of the scalp (i.e., psoriasis, seborrheic dermatitis)
	Infectious conditions of the scalp (i.e., fungal, bacterial, viral)
Other	Dermatomyositis [17]
	Systemic lupus erythematosus
	Syphilis
	Idiopathic
	Anti-cellulite creams containing iodine or thyroid extracts
	Over-the-counter drugs to lose weight
	Traveling from low to high daylight locations (changing time zone)
	Keratolytic shampoos
	Herbal remedies

Clinical Features

Telogen effluvium typically affects scalp hair but is not necessarily limited to the scalp [18]. The hair loss typically occurs about 2–3 months after the causative insult, but it can happen earlier in cases of premature teloptosis, for example, after initiation of topical minoxidil [12]. Patients complain of increased shedding and loss of volume, but thinning is usually not a feature of telogen effluvium as 50% of the scalp hair need to be lost for the scalp to be visible [19]. The hair loss is in most cases not obvious to the physician especially in patients who previously had thick hair. Bitemporal thinning is a common feature of chronic telogen effluvium [8, 19]. It is not uncommon for patients to bring bags of hair (Fig. 10.1) or their hair brush (Fig. 10.2) to appointments to demonstrate to the doctor the severity of their hair loss. Patients with chronic telogen effluvium might even document their daily hair loss with a notebook (Fig. 10.3).

Fig. 10.1

Bag with hair shed by patient in 1 year

Fig. 10.2

Brush demonstrating hair shedding by patient with telogen effluvium

Fig. 10.3

Example of a patient notebook describing hair shedding

The disease can have major psychological impact even when the hair appears to be normal in thickness on exam [2]. This psychologic effect can be seen in both men and women, but it has been reported to be more prominent in women [20].

Acute Telogen Effluvium

Acute telogen effluvium usually ceases within 3–6 months of initial symptom onset [12, 21]. Clinically significant regrowth and recovery usually takes about 6–12 months as hair requires time to grow to an adequate length. Full recovery may be delayed or never realized in older women due to the presence of concomitant androgenetic alopecia and aging follicles [22]. Evidence has suggested that it is relatively common for physicians to diagnose patients with androgenetic alopecia after a delayed recovery from acute telogen effluvium [2].

Chronic Telogen Effluvium

Chronic telogen effluvium is typified by an insidious onset and long fluctuating course with unexplained remissions and recurrences lasting several years [5, 23].

Its cause is usually multifactorial and difficult to establish. It is currently proposed that chronic telogen effluvium may be caused by an intermittent pathologic synchronization of the hair cycle, anagen phase shortening, or early teloptosis. It remains a diagnosis of exclusion, whereby it must be kept in mind that multiple-cause relationships may underlie this type of hair loss, including significant seasonal fluctuations of hair growth and shedding. The condition can resolve completely on its own, but it may take years to even a decade before a cessation in symptoms occurs [24].

Diagnostic Criteria

Telogen effluvium is typically a clinical diagnosis. A hair-pull test should be performed by lightly grasping 40–60 hairs with the fingers and gently pulling the hair away from the scalp avoiding any fast or forceful movement (Fig. 10.4) [8]. Traditionally, it was suggested patients avoid washing hair for 5 days before a pull test, and a test was considered positive if greater than 10% (approximately 5–6 hairs) of the original hairs are extracted; however, newer guidelines state hair brushing and washing can be done any time before a pull test and consider the removal of more than two hairs abnormal [25]. In addition to counting the hairs, it is also useful to visualize the hairs under a microscope to distinguish telogen from anagen roots (Fig. 10.5) [26]. Also, patients should be asked to quantify their shedding during shampooing using the hair-shedding visual scales, which are very helpful to quickly assess excessive hair shedding versus normal hair shedding [27, 28]. History and physical exam findings suggestive of telogen effluvium are outlined in Table 10.3.

Fig. 10.4

Demonstration of the correct method of the hair pull test

Fig. 10.5

Telogen hair bulb visualized using microscopy

Table 10.3

History and physical exam findings suggesting telogen effluvium

History	Physical exam
Acute inciting event (see Table 10.2) in previous 2–5 months before onset of hair loss [2] Trichodynia (pain , discomfort, or paresthesia of scalp) sometimes present, though nonspecific [29] Seasonal exacerbations Patient can identify the exact date when symptoms began	Very positive (more than ten hairs) hair-pull test [8] Microscopic examination of shed hair from hair-pull test showing telogen bulb [30] (see Fig. 10.5) Short regrowing frontal hairs [2] Beau’s lines of nails may signal recent severe medical illness [30] Dermoscopy [31]: Acute: empty follicles, multiple short regrowing hairs of normal thickness, may be associated with variability due to concurrent AGA Chronic: less than 20% hair diameter variability, differentiates vs. androgenic alopecia Found only in chronic telogen effluvium: No changes in hair diameter [5] Bitemporal thinning [5] Decrease in pony tail length and thickness Aggravates in the summer Normal pull test

History

Physical exam

Acute inciting event (see Table 10.2) in previous 2–5 months before onset of hair loss [2]

Trichodynia (pain , discomfort, or paresthesia of scalp) sometimes present, though nonspecific [29]

Seasonal exacerbations

Patient can identify the exact date when symptoms began

Very positive (more than ten hairs) hair-pull test [8]

Microscopic examination of shed hair from hair-pull test showing telogen bulb [30] (see Fig. 10.5)

Short regrowing frontal hairs [2]

Beau’s lines of nails may signal recent severe medical illness [30]

Dermoscopy [31]:

Acute: empty follicles, multiple short regrowing hairs of normal thickness, may be associated with variability due to concurrent AGA