Telogen Effluvium (Stress-Induced Alopecia)

Are You Confident of the Diagnosis?

What you should be alert for in the history

History will include a sudden onset of diffuse shedding. Patients often carry a bag of hair (see Figure 1). Women may report a fear of going bald.

Figure 1.

Telogen effluvium. Not uncommonly patients will bring in bags of hair for examination.

Shedding occurs 3-6 months after a “trigger,” which can be either physical or psychological. Common triggers include high fever, post-childbirth, chronic illness, major surgery, severe emotional disorder, anemia, crash diets, hypothyroidism, or drugs (starting, stopping, or changing oral contraceptive pills and oral retinoids are the most common culprits); however, 33% of the time no trigger is identified.

Characteristic findings on physical examination

The physical examination will show an equal part width on the crown and occipital scalp (Figure 2, Figure 3). On general appearance, most patients will not appear to have a hair loss disorder because you need to lose greater than 50% of hair before hair thinning becomes clinically noticeable. The scalp is normal, without erythema or scarring.

Pull test will be positive, with 3 to 5 hairs per pull if caught in the acute phase. A negative pull test does not exclude the diagnosis because the telogen effluvium may be in a state of resolution.

Figure 2.

Telogen effluvium. Note part width on crown of scalp is similar to part width on occipital scalp (next image) in a 14-year-old. female who presented with diffuse shedding 3 months after a depressive episode.

Figure 3.

Telogen effluvium. Part width on occipital scalp is similar to part width on crown of scalp.

Expected results of diagnostic studies:

The clinical diagnosis in the majority of cases comes from history and physical exam. Hair pull reveals characteristic telogen (club) hairs on direct microscopy (Figure 4, Figure 5).

Figure 4.

Normal telogen hair. (Courtesy of Bryan Anderson, MD)

Figure 5.

Normal anagen hair. (Courtesy of Bryan Anderson, MD)

Focused laboratory tests, as directed from history and exam, include complete blood count (CBC) for anemia, thyroid-stimulating hormone (TSH), and iron studies. A 4mm punch biopsy submitted for horizontal sectioning (able to count hairs vs. vertical sectioning) reveals greater than 25% in telogen phase. Normal percentage of telogen hairs is 10%-20%. This is rarely performed.

Diagnosis confirmation:

Female or male pattern hair loss is the most common cause of hair loss. It features increased part width on crown compared to occiput. Clinically, the patient reports patterned hair loss with or without increased shedding. This condition has a gradual prolonged onset.

Chronic telogen effluvium lasts greater than 6 months. It is characterized by bitemporal recession, with no widening of the central part of the hair. It occurs mostly in women in their 30s and 40s, and can last 5 to 7 years. One needs to distinguish this from female pattern hair loss.

Hypothyroidism is characterized by dry, diffusely sparse hair with loss of the lateral third of each eyebrow. This can be ruled out by TSH level if there are other symptoms present such as fatigue, weight gain, cold intolerance, muscle cramps, and constipation.

Low iron levels are the most frequent abnormal test seen in patients with chronic telogen effluvium. One study showed 63.8% of premenopausal and 36.8% of postmenopausal women with chronic telogen effluvium had iron deficiency; however, this was not a significant increase in iron deficiency compared to controls. Inquire about fad diets. These can be screened for by checking a CBC and iron studies, if indicated.

With anagen effluvium, the history reveals exposure to a chemotherapeutic agent. There is noticeable hair thinning. The hair pull reveals dystrophic anagen hairs on microscopy.

Who is at Risk for Developing this Disease?

Telogen effluvium is seen predominantly in females. It can affect males and females, and individuals of all races.

What is the Cause of the Disease?

For unclear reasons, the triggers shift an increased percentage of growing anagen hairs prematurely into telogen hairs (the shedding hairs). This transition occurs over an approximately 100-day period. Therefore, the hair loss occurs about 3 months after the trigger.

Systemic Implications and Complications

There are no complications associated with telogen effluvium, unless they are related to a systemic disease that triggers telogen effluvium.

Treatment Options

Treatment is primarily education and observation. Remind the distressed patient that hair would not be falling out if new hair was not growing. Reassure the patient that the disorder is reversible and self-limited, with shedding generally occurring over a 3- 6 month period.

Recovery is complete, although it may take 6-12 months for hair to return to baseline. It is important to tell postpartum patients that regrowth may not achieve antepartum color, texture, and length.

This disorder may potentially be prolonged for years (chronic telogen effluvium can last up to 7 years). Part widths, however, remain unchanged.

Provide psychological support to limit anxiety.

Correct any underlying illness that may have been discovered in history as a trigger.

Optimal Therapeutic Approach for this Disease

It is important to educate and reassure patients that the disease is reversible and that the patient will not go “bald” or progress to point where hair thinning is noticeable to outside observers.

Manage the patient’s expectations. Shedding can occur for up to 6 months, and then it may take 6-12 months for complete recovery of hair density back to baseline.

Therapeutic trials, including studies on topical minoxidil and finasteride, are lacking for this condition. Because the condition improves naturally with time, it is difficult to establish an endpoint with a therapeutic intervention. The author (JJM) has not used these therapies for acute telogen effluvium but has had unsatisfactory results with limited experience of finasteride (2.5mg daily) in females with chronic telogen effluvium.

Provide psychological support to limit anxiety.

Correct any underlying disorders that may have been discovered as a trigger.

Patient Management

Observation is the first step in patient management.

Expect recovery in 6-12 months; however, chronic telogen effluvium can last up to 7 years.

Monitor females with diffuse shedding at 6- or 12-month intervals, as some may evolve into female pattern hair loss.

Diffuse shedding is the initial presentation of evolving female pattern hair loss.

Unusual Clinical Scenarios to Consider in Patient Management

Chronic telogen effluvium occurs when there is increased shedding for greater than 6 months, there is no widening of the central part of the hair, and there is no miniaturization of the hair follicles on a 4mm punch scalp biopsy submitted for horizontal sectioning.

What is the Evidence?

Marks, JG, Miller, JJ. Principles of dermatology. 2006. pp. 263-5. (Provides an easy-to-read introductory section on telogen effluvium, including an overview, physical exam findings, differential diagnosis, laboratory findings, therapy, course, and pathogenesis of telogen effluvium)

Headington, JT. “Telogen effluvium”. Arch Dermatol. vol. 129. 1993. pp. 356-63. (This article offers a well-detailed review of the topic of telogen effluvium. The article describes the pathophysiology and explores the proposed mechanisms for this disorder. As a review article, this source helps to provide a broad overview of the topic. Although this article was written in 1993, it still highlights important facts that have not changed over the years.)

Harrison, S, Sinclair, R. “Telogen effluvium”. Clin Exp Dermatol. vol. 27. 2002. pp. 389-95. (This journal article offers a detailed review of telogen effluvium, including specifics about acute telogen effluvium and chronic telogen effluvium. The source also describes chronic diffuse telogen hair loss and covers a differential of causes for the hair loss, including multiple nutritional deficiencies and systemic illnesses. This article was helpful for differentiating the multiple causes of diffuse hair loss and explaining how best to test for each possibility.)

Whiting, DA. “Chronic telogen effluvium”. Dermatol Clin. vol. 14. 1996. pp. 723-31. (This journal article offers a detailed explanation of chronic telogen effluvium. The article provides a useful clinical description of chronic telogen effluvium.)

Habif, T. Clinical dermatology. 2009. (This book provides an overview of anatomy, physiology, evaluation of hair, generalized hair loss, localized hair loss, and trichomycosis.)

Rushton, DH. “Nutritional factors and hair loss”. Clin Exp Dermatol. vol. 27. 2002. pp. 395-404. (This journal article provides a review of the literature about nutritional disorders and hair loss. It distinguishes hair loss with and without scaling, and also focuses on iron deficiency.)

Olsen, EA. “Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups”. Journal Amer Acad Derm. vol. 63. 2010. pp. 991-9. (This research determined that while iron deficiency is increased in women, it is not increased in patients with chronic telogen effluvium, when compared to controls.)