What is Telogen Effluvium?
Telogen Effluvium (TE) is a common form of temporary hair loss that involves increased shedding of hair in response to stress placed on the body.
The term “effluvium” originates from the Latin root “to flow out”, and the Oxford Dictionary defines effluvium as “an unpleasant or harmful odor, secretion, or discharge”. While telogen effluvium—or the discharge of hairs that have been accelerated into the telogen phase of their growth cycle—may be unpleasant, it is NOT harmful and typically sees self-remission in 95% of patients within several months of cessation of the stressor. TE, as a marker of homeostatic disruption, should prompt a systemic evaluation of the patient if symptoms persist for more than 6 months.
Understanding Telogen Effluvium
The hair growth cycle consists of 4 phases: anagen (growth), catagen (involution), telogen (resting), and exogen (shedding). Sometimes, exogen is combined with telogen into a composite third phase. Anagen is a period of active growth lasting 3-6 years where the hair is securely attached to the nourishing papilla and extends in length and girth.
A shift into catagen (involution), sees a diminutive process driven by cell death. The diameter of the hair can be reduced by 15% overall, while the intradermal portion also shortens vertically and converts into club hair. This phase can last a few weeks before shifting into telogen, which is the phase of dormancy, or rest, and lasts several months. Normally, 10–15% of our hair exists in the telogen phase, which results in the shedding and recycling of 50–100 or so hairs daily (exogen).
Also Read: Temporary Hair Loss: It’s Temporary But Can Be Worrisome
While the cycling of hair is typically a well-choreographed phenomenon, any disruption to the cycling that results in a larger proportion of hairs (up to 30%) being shifted prematurely into telogen will result in Telogen Effluvium and the shedding of more than 100 or so hairs daily. Several mechanisms have been proposed for this accelerated entry into the telogen phase, such as immediate anagen release, delayed anagen release, short anagen syndrome, immediate telogen release, and delayed telogen release.
However, the common basis of all of these proposed mechanisms is an increased number of hairs that have been converted into club hairs and shed synchronously over a finite (usually) period of time. Because the telogen phase typically lasts several months, the enhanced shedding will also continue for 2-3 months after the stressor is removed.
Chronic vs Acute
While telogen effluvium is typically a self-limited and self-reversing phenomenon lasting less than 6 months (acute TE), some patients will experience a continuation of this “hyper-recycling” for a much longer time. Short anagen syndrome is thought to underlie chronic telogen effluvium, as shortening of the anagen phase leads to more frequent overall cycling of the hair.
Patients with chronic TE may complain of an inability to gain length in their hair and the persistence of short, normal-caliber hairs along their hairlines. Additionally, emotional distress incurred during the acute phase of TE can sometimes become its own stressor, feeding the process forward.
Symptoms
An episode of telogen effluvium can be dramatic, with hair falling out in handfuls, overall thinning, and an increased scalp show. Thinning of eyebrows and pubic hair is also a frequent feature and is generally seen to recover faster than the scalp. Coincident effects on the nails, in the form of horizontal grooves or Beau’s lines, can help determine the time of insult. Additionally, one’s assessment of the change in their ponytail size can provide a helpful tracking tool during both hair loss and recovery.
While diffuse thinning can be distressing, patients with isolated TE do not usually exhibit other scalp pathologies such as rash, itching, or pain. Increased sensitivity of the scalp and paresthesias have been reported rarely.
Causes
Stress may be placed on the body in many ways, best examined by category:
- Physical causes, such as major surgery, general anesthesia, illness, pregnancy, etc.
- Mental causes, including starting a new job, preparing for a major examination, etc.
- Emotional causes, like depression or anxiety; major life changes, as seen in divorce or the death of a loved one;
- Foundational causes, which involve considerations of nutritional deficiency, hormonal imbalance, sleep deprivation, caloric supply/demand mismatch, etc.
- Medications, including several antihypertensives, anticonvulsants, anticoagulants, and others.
In about 33% of cases, a direct cause cannot be identified. Usually, telogen effluvium occurs about 4 to 6 weeks after one of these insults and begins to resolve after a few months’ time.
The addition of stress to the body’s routine functioning leads to the activation of several watchdog systems, such as the immune system, the fight-or-flight response system, and catabolic/anabolic regulation, prioritizing the survival of the body’s major organ systems at the expense of hair growth. Hormonal imbalances involving the thyroid gland or encountered during pregnancy or menopause can also lead to changes in the body’s metabolic processing. The shift of many hairs rapidly from anagen into telogen signals a conservation effort, which is only relaxed after cessation of the stressor. Deficiencies in the body’s reserves of nutrients such as iron, vitamins B and D, zinc, protein, and essential fatty acids may also contribute to decreased stress tolerance and increased TE susceptibility and duration.
Diagnosis
The diagnostic process entails a careful and comprehensive history-taking, particularly focusing on the period 6–12 months prior to the onset of shedding, by which one will often identify the causative stressor. A physical examination of a patient with acute TE will show diffuse thinning, increased scalp appearance, and the collection of more than 100 shed hairs after abstaining from shampooing for 5 days, of which less than 10% will be vellus.
Dermoscopy will show an increased number of short hairs as well as a global thinning of existing hairs with up to 20% variability in caliber. Some empty follicular ostia may also be present. In chronic TE, patients may additionally show many short, normal-caliber hairs in the frontal area. This is in contrast to findings of increased variability in caliber and greater miniaturization in androgenetic alopecia.
A “pull test” can be conducted, whereby approximately 20–60 hairs are grasped together at their base near the scalp and firmly pulled. If more than 10% of those grasped hairs leave the scalp, the test is considered positive and indicative of increased active shedding.
A trichogram, or “pluck test”, entails the actual plucking of 40–60 adjacent hairs from a defined area and the examination of their intradermal portions under the microscope. A reduced anagen vs telogen ratio, demonstrating the presence of greater than 25% telogen hairs, establishes telogen effluvium.
Telogen effluvium can often coexist with or resemble other conditions, so chronic, refractory, or atypical findings may be further evaluated by additional tests, including the following:
- Scalp Biopsy: Multiple sites are recommended for increased accuracy; a reduction in the anagen vs telogen ratio with the absence of peribulbar infiltrate and follicular miniaturization supports a diagnosis of isolated TE. The addition of follicular miniaturization argues for coincident androgenetic alopecia. The presence of inflammatory infiltrates will guide the diagnosis of autoimmune or inflammatory alopecias.
- Blood Tests: To evaluate for nutritional deficiencies (i.e., ferritin, vitamins B6, B12, D, and folic acid), autoimmune disease, or hormonal imbalance (i.e., thyroid stimulating hormone [TSH]), the treatment of which will assist with recovery.
Differential Diagnosis
When a patient presents with a large, rapid hair fall, a few other diagnoses should be considered:
- Anagen effluvium (shedding of anagen phase hair often after chemotherapy or infection—typically faster than TE)
- Diffuse alopecia areata (often has more prominent thinning in retroauricular (behind the ear) and occipital areas; dermoscopic features include exclamation mark hairs and yellow and black dots, as well as the presence of peribulbar infiltrate on histology).
- Androgenetic alopecia (especially female, when the hair loss is a bit slower and longer lasting, has a frontal predominance, and greater miniaturization is present).
- Hair shaft defects, such as loose anagen hair syndrome
Treatment
The treatment of TE is often just patience, as 95% of cases are self-resolving within 2–3 months of removal of the triggering factor. Cessation of the additional stress allows for the return of the body’s routine functioning and the resumption of the normal hair cycle. As the final hairs to convert to telogen will continue to shed for a few months after systemic health is restored, the reassurance and encouragement of the patient are paramount during this time.
It is especially important to highlight that while hair shedding may return to its normal rate a few months after resolution of the stressor, it may take 18 months or more to regain the previous fullness they previously enjoyed because the new hairs grow at a rate of 0.25–0.5 inches per month.
When anxiety over hair loss causes prolongation of shedding or the patient has had shedding for more than 6 months and recovery seems incomplete with respect to density or length, several treatments may be helpful to promote recovery:
- Over-the-counter topical minoxidil can help promote the return to and prolongation of the anagen phase.
- Ensuring proper nutrition, including adequate intake of complete proteins, essential fatty acids, complex carbohydrates, and total calories, can support the rebuilding of hair and its ability to grow long.
- Supplementation of deficiencies such as iron, vitamin D, biotin, and others can ensure optimal cell signaling and oxygen delivery.
- Platelet-rich plasma (PRP) and low-level laser light therapy have also been shown to assist with the repair of cellular damage that prolongs telogen effluvium.
Prognosis and Recovery
Again, telogen effluvium is typically a self-limited response to the addition of a stressor to the body. About 95% of patients will fully recover within 2–3 months of the cessation of the stressor. When underlying hormonal issues or nutrient deficiencies cause prolonged shedding beyond 6 months, it is important to address those as well as rule out other systemic or coincident issues.
TE can cause a dramatic, sudden, and visible thinning of hair, the psychological impact of which can be devastating. Without appropriate reassurance and emotional support, the anxiety and concern about possible permanent loss can create a forward feeding process that can move acute telogen effluvium into a chronic state. Stress management and therapy directed towards reducing or redirecting this anxiety are often overlooked but should be considered successful treatment adjuncts.
Prevention and Healthy Hair Practices
Because telogen effluvium is a response to the addition of a stressor, it makes sense that certain lifestyle practices can shore up the body’s reserves and defenses, reducing the incidence and duration of a TE episode. Nutritional support to ensure adequate iron stores, vitamin levels, balanced protein, fat, and carbohydrate intake, and hydration are easy means to keep the body resilient. More and more, we are seeing a rise in mental load from a variety of sources—work, relationships, and finances—which behooves us to incorporate mindfulness and stress management into our daily lives. The benefits of daily exercise and adequate sleep cannot be overstated, as both are crucial in cellular repair processes.
Expert Opinion
I have seen many instances of telogen effluvium in my practice, both acute and chronic, and have successfully treated them by incorporating holistic treatment plans that address lifestyle, diet, sleep, and stress, in addition to reversing hormonal imbalances and nutritional deficiencies and using medications and/or regenerative capabilities. But I think the most important piece to address in cases of telogen effluvium is really the emotional one.
Most of my patients have already seen their primary care physician or even a dermatologist prior to scheduling an appointment with me but find that their concerns were quickly diagnosed and underexplained, without adequate time to ask questions or feel secure in their understanding. They present to me in a state of panic and loss of control, so a large part of my therapeutic plan includes education about the natural history of telogen effluvium, real-time sharing of their dermoscopy exams, short-interval follow-up for reassurance, and the offer of a variety of growth-promoting therapeutic options that they can elect to undergo should the shedding remain persistent.
The majority of my patients are also comforted by my sharing of personal experience with telogen effluvium, both after my pregnancies and during the pandemic. When seeing their physician as a patient, many return to hopefulness that my reassurances and treatment plans will work for them.
For a consultation with a hair restoration surgeon, access our Find A Doctor tool where you can search for an ISHRS member by location.