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Everything You Wanted to Know (Including Information You Probably Would Rather Not Know) About Telogen Effluvium
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.
To understand telogen effluvium, we need to have some knowledge of the hair growth cycle. On the human scalp, hair does not grow continuously. The anagen (growing) phase for terminal hair can extend 3 to 7 years. In this context, ‘terminal’ has the connotation of ultimate or optimum, rather than finality. So, ‘terminal’ is the word used to describe the thick, full, mature hair shaft. 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, because of its characteristic shape, will spontaneously shed, while a new hair shaft is forming within the hair canal. There is usually a collection of friable debris, consisting of dead cells and connective tissue at the scalp end of the shed hair. However, because the debris is unorganized and easily abraded off, it may be absent.
In the scalp of a healthy, young human adult, approximately 90% of the hair follicles will be in the anagen phase and approximately 10% will be in the telogen phase. Less than 1% will be in the catagen phase. The human scalp contains 100,000 hairs. At any one time, 10% or 10,000 of the hairs are in the telogen phase, which is approximately 100 days long. Statistically, 1% or 100 of those hairs will be at the end of the telogen phase and will shed spontaneously. This is the explanation of why it is normal to shed up to 100 hairs per day.
When excessive amounts of hair simultaneously switch from anagen into telogen and subsequently shed several months later, the phenomenon is referred to as a telogen effluvium. Statistically, about one half of all cases of telogen effluvium begin at 11 to 13 weeks after the inciting cause, but variations from 4 to 16 weeks have also been reported. 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 effluvium has 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 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 hair follicles in the back of the head to enter the first telogen phase close to the time of birth and for these hairs to subsequently shed 2 to 3 months later. In the human infant, waves of synchronized hair growth occur before establishment of the mosaic pattern of hair growth, which is usually established by the end of the first postnatal year.
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. The cells of the hair follicles on the scalp are the second most active group of cells in the body. Only the tissues producing red blood cells in the bone marrrow are more active. So, any significantly severe systemic insult can suddenly send a signal to many of the follicles to temporarily shut down, shifting from anagen to telogen. At the end of the telogen phase, those hairs will shed. 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 telogen effluvium is never caused by topical medications.
Among the most easily diagnosable causes of a telogen effluvium and the textbook prototype for a telogen effluvium would be the episodes 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 is regrown 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, anemias, 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 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
Making the diagnosis of a telogen effluvium is 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. Since a telogen effluvium is not limited to the hair follicles at risk for male pattern baldness 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 expect the shedding from a telogen effluvium.
In reality, a telogen effluvium is simply an exaggeration of a normal process. The dilemma is that the process occurs prematurely and it occurs to a large number of hair follicles at the same time, so it provokes a lot of anxiety. In an uncomplicated telogen effluvium, the resolution is spontaneous and treatment can be limited to reassurance. 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. If the inciting cause, whether it be some medication, stress, illness, etc., can be identified, then it should be avoided or discontinued or treated, whichever is appropriate.
Unfortunately, a telogen effluvium can be the harbinger of the onset of male pattern baldness or the initial event in a period of accelerated male pattern baldness. 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. At the International Society for Hair Restoration Surgery in Vancouver, B.C. in August 12-15, 2004, data was presented that showed the ability of topical minoxidil to ameliorate the shedding in a telogen effluvium, due to its ability to (1) prolong anagen, (2) delay or prevent telogen, and to (3) induce anagen in the hair follicles. At a study performed at UCLA, a 5% topical minoxidil was proven to reduce the shedding and to promote recovery of hair in telogen effluvium.
Patients who are eager to play an active role in their treatment of a telogen effluvium may wish to use a 5% minoxidil solution. DHT inhibitors are not useful for the treatment of telogen effluviums, because such agents do not decrease the amount of shedding, nor do they promote an earlier regrowth of the hair. However, there are no contraindications to the concomitant use of DHT inhibitors for the treatment of male pattern baldness, while you are experiencing a telogen effluvium.
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.
When hair is shed within days or a few weeks after an insult to the hair follicles, that would constitute an ‘anagen effluvium’ and could be the subject of another article.
Schiff BC, Kern AB: Study of postpartum alopecia. Arch Dermatol 87:609, 1963
Taylor JS. In Maibach HI: Occupational and Industrial Dermatology, 2nd ed, p 109. Chicago, Year Book Medical Publishers, 1987
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
Wise RP, Kiminyo KP, Salive ME: Hair loss after routine immunizations. JAMA 1997 Oct 8; 278(14): 1176-8
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
Everything You Wanted to Know (Including Information You Probably Would Rather Not Know) About Telogen Effluvium
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.
To understand telogen effluvium, we need to have some knowledge of the hair growth cycle. On the human scalp, hair does not grow continuously. The anagen (growing) phase for terminal hair can extend 3 to 7 years. In this context, ‘terminal’ has the connotation of ultimate or optimum, rather than finality. So, ‘terminal’ is the word used to describe the thick, full, mature hair shaft. 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, because of its characteristic shape, will spontaneously shed, while a new hair shaft is forming within the hair canal. There is usually a collection of friable debris, consisting of dead cells and connective tissue at the scalp end of the shed hair. However, because the debris is unorganized and easily abraded off, it may be absent.
In the scalp of a healthy, young human adult, approximately 90% of the hair follicles will be in the anagen phase and approximately 10% will be in the telogen phase. Less than 1% will be in the catagen phase. The human scalp contains 100,000 hairs. At any one time, 10% or 10,000 of the hairs are in the telogen phase, which is approximately 100 days long. Statistically, 1% or 100 of those hairs will be at the end of the telogen phase and will shed spontaneously. This is the explanation of why it is normal to shed up to 100 hairs per day.
When excessive amounts of hair simultaneously switch from anagen into telogen and subsequently shed several months later, the phenomenon is referred to as a telogen effluvium. Statistically, about one half of all cases of telogen effluvium begin at 11 to 13 weeks after the inciting cause, but variations from 4 to 16 weeks have also been reported. 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 effluvium has 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 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 hair follicles in the back of the head to enter the first telogen phase close to the time of birth and for these hairs to subsequently shed 2 to 3 months later. In the human infant, waves of synchronized hair growth occur before establishment of the mosaic pattern of hair growth, which is usually established by the end of the first postnatal year.
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. The cells of the hair follicles on the scalp are the second most active group of cells in the body. Only the tissues producing red blood cells in the bone marrrow are more active. So, any significantly severe systemic insult can suddenly send a signal to many of the follicles to temporarily shut down, shifting from anagen to telogen. At the end of the telogen phase, those hairs will shed. 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 telogen effluvium is never caused by topical medications.
Among the most easily diagnosable causes of a telogen effluvium and the textbook prototype for a telogen effluvium would be the episodes 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 is regrown 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, anemias, 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 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
Making the diagnosis of a telogen effluvium is 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. Since a telogen effluvium is not limited to the hair follicles at risk for male pattern baldness 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 expect the shedding from a telogen effluvium.
In reality, a telogen effluvium is simply an exaggeration of a normal process. The dilemma is that the process occurs prematurely and it occurs to a large number of hair follicles at the same time, so it provokes a lot of anxiety. In an uncomplicated telogen effluvium, the resolution is spontaneous and treatment can be limited to reassurance. 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. If the inciting cause, whether it be some medication, stress, illness, etc., can be identified, then it should be avoided or discontinued or treated, whichever is appropriate.
Unfortunately, a telogen effluvium can be the harbinger of the onset of male pattern baldness or the initial event in a period of accelerated male pattern baldness. 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. At the International Society for Hair Restoration Surgery in Vancouver, B.C. in August 12-15, 2004, data was presented that showed the ability of topical minoxidil to ameliorate the shedding in a telogen effluvium, due to its ability to (1) prolong anagen, (2) delay or prevent telogen, and to (3) induce anagen in the hair follicles. At a study performed at UCLA, a 5% topical minoxidil was proven to reduce the shedding and to promote recovery of hair in telogen effluvium.
Patients who are eager to play an active role in their treatment of a telogen effluvium may wish to use a 5% minoxidil solution. DHT inhibitors are not useful for the treatment of telogen effluviums, because such agents do not decrease the amount of shedding, nor do they promote an earlier regrowth of the hair. However, there are no contraindications to the concomitant use of DHT inhibitors for the treatment of male pattern baldness, while you are experiencing a telogen effluvium.
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.
When hair is shed within days or a few weeks after an insult to the hair follicles, that would constitute an ‘anagen effluvium’ and could be the subject of another article.
Schiff BC, Kern AB: Study of postpartum alopecia. Arch Dermatol 87:609, 1963
Taylor JS. In Maibach HI: Occupational and Industrial Dermatology, 2nd ed, p 109. Chicago, Year Book Medical Publishers, 1987
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
Wise RP, Kiminyo KP, Salive ME: Hair loss after routine immunizations. JAMA 1997 Oct 8; 278(14): 1176-8
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