Telogen Effluvium (TE)

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About Telogen Effluvium (TE)

Telogen effluvium (TE) is probably the most common reason for trichology consultation among women.

It is type of non-scarring alopecia that is characterised by higher shedding of the hair than physiologically expected. It is normal to shed up to 100-150 hairs per day. The reason for hair shedding is alteration of the hair cycle.

There can be two types of Telogen Effluvium (TE) acute and chronic.

Acute Telogen Effluvium (TE):

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Onset of shedding starts about 2-3 months (some studies show 3-4months) after the triggering event.
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Hair loss lasts less than 6months.
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Once the triggering factor is corrected or removed the TE can reverse.
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It may take 6-12months before the full recovery of lost hair.

Chronic Telogen Effluvium (TE):

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Hair shedding persists over prolong period, over 6months.
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The amount of hair shedding fluctuates with acute episodes of TE.
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It is characterised by thinner and shorter hair at the temporal and frontal areas.

Normal hair cycle

Hair cycle consist of three phases: growing phase called anagen, then involuting phase called catagen and end of life resting phase called telogen.

Anagen phase of hair growth lasts for about two to five years, followed by catagen stage of cell apoptosis (death) lasting for about three to six weeks and then followed by the end-of-life telogen phase lasting for about three to five months.

At once about 85-90% is in growing stage and about 10-15% of the hair in end-of-life stage.

What happens during Telogen Effluvium (TE) with hair cycle?

Due to underlying causes the follicles are moving from anagen growing phase to end of cycle telogen phase prematurely.
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Causes of Telogen Effluvium (TE)

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Medical conditions like both hyper and hypothyroidism, hormonal imbalance, liver or kidney failure, Inflammatory bowel disease (IBD), etc.
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Medications like contraception pills, retinoids, antidepressants, beta-blockers, ACE inhibitors, etc.
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Physiological stress like fever, surgical procedure, childbirth (TE after childbirth called postpartum alopecia), chronic systemic illness.
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Dietary restrictions and deficiencies like chronic starvation, sudden weight loss, restricted caloric intake can lead to reduction in protein, fatty acid and Zinc, Selenium, vitamin B12 intake. Low Iron and low Ferritin can be a triggering factors for TE type of hair loss. Vitamin D is vital for cell growth and insufficient amount can also lead to TE.
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Discontinuation or initiation of Minoxidil causes Telogen Effluvium (TE). When using Minoxidil the anagen growing phase is prolonged and after discontinuation the catagen and telogen stages onset that results in hair shedding. When Minoxidil is initiated at the first time or restarted after a break in treatment, the telogen phase is shortened causing hair shedding due to entry of the hair into a new cycle.
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Emotional stress can be due to a hair loss, therefore the link between emotional stress and hair loss is ambiguous.
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Seasonal changes may influence hair cycle but not scientifically proven yet. It has been suggested that a change to a warner temperature causes hair loss, after hair has been in prolonged telogen phase due to cold.

Diagnosis

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Identify causative factor and remove it if possible. In some cases, chronic TE is caused by medications that cannot be replaced or by chronic medical conditions that might have relapse from time to time.
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Both hyper and hypothyroidism can cause TE that usually reversable when thyroid function is treated.
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Iron deficiency is associated with diffused hair thinning in women.
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Port-partum effluvium onsets usually between month one to month four but can continue for several month. Occasionally, it can uncover underlying Female Pattern Hair Loss (FPHL).
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Extreme diets are frequent cause of TE, that can be reversed after stabilising the normal body weight and correcting any of nutritional deficiencies.
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How to identify causative factor?

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Full Blood test, including thyroid function, vit D and B12
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Hormonal tests
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Gathering medical history
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Correct diagnosis through trichoscopy, pull test, medical photography and biopsy. In most cases the diagnosis of TE can be done though trichoscopy, however in some cases we might need to do additional investigation and perform punch biopsy. We use small puncture device that removes small tissue sample of the scalp with hair follicle. The sample is sent to the laboratories were examined by the specialist scalp and hair pathologist.

Treatment

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Identifying and removal of causative factor.
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Oral supplements of Iron, vit D, Zinc, Biotin, Selenium and other nutricosmetics if there is a deficiency.
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Platelets Rich Plasma procedure to increase anagen stage using growth factors.
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We do not recommend using oral or topical Minoxidil in Acute TE as initiation of Minoxidil treatment will increase hair shedding and can be very distressing for the patient. Oral Minoxidil can be considered to use in some cases if there is underlying Female Pattern Hair Loss or resistant chronic TE for continuous use. Patient should be explained that the discontinuation of Minoxidil treatment will lead to Telogen Effluvium.