Telogen Effluvium - Why, When, and How
Article by HairlossTalk.com
February 8, 2004
Dr. Richard Lee covers some of the most common questions regarding Telogen Effluvium - a condition that can masquerade itself as many things, including male and female pattern baldness...
Effluvia? Effluviums? Even the name is confusing. According to Dorland’s
Medical Dictionary, telogen [Gk, telos, end + genein, to produce] is the resting
phase of the hair growth cycle lasting approximately 100 days and effluvium: [L,
effluvium, a flowing out] is defined as an outflow, which may pertain to sudden,
severe hair shedding.
The Hair Growth Cycle
To understand telogen effluvium, we need to have some knowledge of the hair growth
cycle. Hair does not grow continuously on the human scalp. The anagen (growing)
phase for terminal hair can extend 3 to 7 years and is a reflection of the size
of the hair follicle. Catagen is the transitional portion of the hair growth cycle,
between anagen and telogen and lasts only 1 to 2 weeks. During this time, there
is a rapid involution and regression of the hair follicle. The hair follicle then
enters the telogen phase, which is a relatively fixed period of time, approximately
100 days, regardless of the size of the hair follicle. There is no growth of the
hair shaft during this phase. It is at the end of the telogen phase that the entire
hair shaft, also often referred to as the club hair, will spontaneously shed,
while a new hair shaft is forming within the hair canal. The white bulb at the
end of the hair, along with the loosely attached collection of friable debris
gives the shed hair its characteristic appearance.
In the scalp of the healthy, young human adult, approximately 90% of the hair
will be in the anagen (growth) phase and approximately 10% will be in the telogen
(dormancy) phase. Less than 1% will be in the catagen (transitional) phase.
When you consider that the scalp contains 100,000 hairs, with 10,000 in the
telogen (dormancy) phase... and 1% of those hairs in the telogen phase will
be at the end of the 100 day long phase, you can easily understand why it is
normal to shed 100 hairs per day.
What is Telogen Effluvium?
When excessive amounts of hair simultaneously switch from anagen (growth) into
telogen (dormancy) and subsequently shed several months later, the phenomenon
is referred to as a telogen effluvium. Rarely are more than 50% of the hairs on
the head involved. Telogen effluviums can be acute or chronic. When the shedding
lasts more than six months or persistently recurs, it is referred to as a chronic
telogen effluvium. Chronic telogen effluviums have been reported mainly in women.
No racial predilection exists. Although telogen effluvium can affect hair on all
parts of the body, generally, only loss of scalp hair is symptomatic. The exact
prevalence is not known and getting accurate statistics would be very difficult,
but the condition is quite common. Telogen effluvium can occur at any age. It
is likely that most adults have experienced an episode of telogen effluvium at
some point in their lives and, unbeknownst to most people, everybody has experienced
the phenomenon early in life. In fact, mothers have been more aware of telogen
effluviums in newborns and babies than most doctors have ever been. It is typical
for a band like area of occipital hair follicles to enter the first telogen close
to the time of birth and for these hairs to shed 2 to 3 months later. In the human
infant, waves of hair growth occur before establishment of the mosaic pattern,
which is usually present by the end of the first postnatal year.
What causes Telogen Effluvium?
In order to cause a large number of hair follicles to simultaneously switch
from the anagen (growing) phase into the telogen (resting) phase, the body has
to undergo some systemic insult. A telogen effluvium is not caused by topical
medications. But because there is a required time lapse of several months between
the inciting cause and the excessive shedding of hair, the exact cause of the
telogen effluvium is often not positively identified.
A typical and common case of telogen effluvium would be the episode of severe
shedding of hair that may occur approximately 100 days after a woman has given
birth. The inciting factor is probably the abrupt hormonal changes that occur
at the end of pregnancy. All of the hair grows back within a year.
Other causes of telogen effluvium include illness, major physical trauma, menopause,
crash diets, severe psychological stress, major surgery (especially with general
anesthesia), hypo- or hyperthyroidism, anemia's, acute and severe blood loss,
heavy metal poisoning, etc. Chronic illness such as malignancy, and any chronic
debilitating illness, such as systemic lupus erythematosus, end-stage renal disease,
or liver disease can cause telogen effluvium. Immunizations also have been reported
to cause acute hair shedding. Even jet lag and job changes have been reported
to cause a telogen effluvium. In the United States, oral medications may very
well be the most common cause of telogen effluviums. The list of medications associated
with telogen effluviums is extensive and includes retinoids, beta-blockers, anticoagulants,
SSRI’s, non-steroidal anti-inflammatories, calcium channel blockers, etc.
In any and all cases, the common factor is metabolic or physiologic stress several
months before the start of the hair shedding.
How do I know if I have TE?
Making the diagnosis of a telogen effluvium is usually quite straightforward.
A ‘hair pull’ will determine whether or not a disproportionate number
of hair follicles are in the telogen phase. And this is a test, which the patient
can do himself or herself. Pinch a bunch of hair between your thumb and middle
finger. You will have approximately 25 to 30 hairs within the pinch. Give the
bunch of hair a sharp tug. Repeat this tug in several places over the scalp.
It would be normal to dislodge one or two hairs with each pull, because approximately
10% of the hairs on the scalp are in the telogen phase. The hairs that are dislodged
should have a small, friable, whitish bulb on the scalp end. If you pull out
more than 4 or 5 hairs in each pull, it’s likely that you are having a
period of telogen effluvium. For an accurate pull test, it is important that
you have washed your hair regularly, i.e. daily or every other day. With infrequent
washing, more hair than normal may pull out giving an erroneous interpretation.
Since a telogen effluvium is not limited to the hair follicles at risk for MPB
or FPB, shedding can involve hair on any part of the scalp (and even body hair).
The underlying scalp has a normal appearance without scarring or inflammation
and there should not be any areas of complete alopecia. A close examination
of the scalp may reveal a higher than expected number of short new hairs growing
in.
If there is an obvious history of an inciting event and the time elapsed between
the inciting event and the excessive shedding is consistent with the approximate
length of a telogen phase, laboratory studies are of little use in making the
diagnosis. Although a scalp biopsy can be performed to confirm the diagnosis,
it would seldom be necessary if the history is characteristic and a ‘hair
pull’ produces numerous telogen hairs. There are no signs or symptoms,
which allow you to anticipate the shedding from a telogen effluvium.
Treating Telogen Effluvium
Because acute telogen effluvium is in reality a normal process, which occurred
prematurely in a synchronized manner to a large number of hair follicles, and
which resolves spontaneously, treatment can be limited to reassurance. The identifiable
inciting factor should be avoided or discontinued or treated, whichever is appropriate.
Assuming there is no intervening pathological process, all of the hair will
be replaced in six to twelve months and the replacement hair should be identical
to the hair that was shed.
Telogen Effluvium and Miniaturization
Unfortunately, a telogen effluvium can be the harbinger of the onset of Male
Pattern Baldness or the initial event in a period of accelerated MPB. In these
cases, which are fairly common, the hair also grows back, but the hair may be
significantly finer and smaller, because the hair follicles affected have miniaturized
by the MPB process. While 5% topical minoxidil is not proven to promote recovery
of hair in telogen effluvium, this medication has a theoretical benefit because
minoxidil acts directly on hair follicles and promotes anagen growth. Patients
who are eager to play an active role in their treatment may wish to use a 5%
minoxidil solution. The use of DHT inhibitors is not recommended for the treatment
of telogen effluvium.
In Conclusion
Chronic telogen effluvium is more likely to be caused by a chronic metabolic
abnormality and is less likely to resolve rapidly. The underlying cause or disorder
should be avoided or discontinued or treated, whichever is appropriate, and
the patient should have reassurances that the hair loss will not progress to
baldness.
Hair transplantation is not a recommended treatment for telogen effluvium.
References:
Barman JM et al: The first stage in the natural history of the human scalp hair
cycle. J Invest Dermatol 48:138, 1967
Bertolino, A and Freedberg, I. M.: Disorders of Epidermal Appendages and Related
Disorders. Fitzpatrick, T.B, et al: Dermatology in General Medicine. McGraw-Hill,1993,
685-686
Brodin MB: Drug-related alopecia. Dermatol Clin 1987 Jul; 5(3): 571-9
Camacho F: Alopecias due to telogen effluvium. In: Camacho F, Montagna W, eds.
Trichology: Diseases of the Pilosebaceous Follicle. Madrid: Aula Medica Group
1993: 403-410.
Goette DK, Odom RB: Alopecia in crash dieters. JAMA 1976 Jun 14; 235(24): 2622-3
Headington JT: Telogen effluvium. New concepts and review. Arch Dermatol 1993
Mar; 129(3): 356-63
Kligman AM: Pathologic dynamics of human hair loss. I. Telogen effluvium. Arch
Dermatol 1961; 83: 175-198.
Rushton DH: Management of hair loss in women. Dermatol Clin 1993 Jan; 11(1): 47-53
Whiting DA: Chronic telogen effluvium: increased scalp hair shedding in middle-aged
women. J Am Acad Dermatol 1996 Dec; 35(6): 899-906
Wise RP, Kiminyo KP, Salive ME: Hair loss after routine immunizations. JAMA 1997
Oct 8; 278(14): 1176-8
HLT
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