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Telogen Effluvium Clinical Presentation

  • Author: Elizabeth CW Hughes, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: May 03, 2016
 

History

The symptom of both acute and chronic telogen effluvium is increased hair shedding. Patients usually only complain that their hair is falling out at an increased rate. Occasionally, they note that the remaining hair feels less dense. In both forms of telogen effluvium, hair is lost diffusely from the entire scalp. Complete alopecia is not seen.

Acute telogen effluvium is defined as hair shedding lasting less than 6 months. Patients with acute telogen effluvium usually complain of relatively sudden onset of hair loss. Careful questioning usually reveals a metabolic or physiologic stress 1-6 months before the start of the hair shedding. Physiologic stresses that can induce telogen effluvium include febrile illness, major injury, change in diet, pregnancy and delivery, and starting a new medication. Immunizations also have been reported to cause acute hair shedding. Papulosquamous diseases of the scalp, such as psoriasis and seborrheic dermatitis, can produce telogen effluvium.

Chronic telogen effluvium is hair shedding lasting longer than 6 months. The onset is often insidious, and it can be difficult to identify an inciting event. Because of the duration of the hair shedding, patients are more likely to complain of decreased scalp hair density, or they may note that their hair appears thin and lifeless.

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Physical

The physical examination is the same in both acute and chronic telogen effluvium. Physical findings are sparse. Usually, the physician does not appreciate a decrease in hair density. However, if the patient's hair has been falling out for several months, the hair may appear thin when compared with old photographs.

Depending on the duration of hair loss, close examination of the scalp may reveal a higher than expected number of short new hairs growing. Because hair grows at a nearly constant rate of approximately 1 cm per month, the duration of the hair shedding can be estimated by measuring the length of the short hairs. Trichoscopy can be helpful in visualizing the hairs.[7]

In active telogen effluvium, the gentle hair pull test will yield at least 4 hairs with each pull. If the patient's active shedding has ceased, the hair pull will be normal. Forced extraction of 10-20 hairs will yield a large percentage of telogen hairs. If greater than 25% of extracted hairs are in telogen, the diagnosis of telogen effluvium is confirmed.

There is one caveat to reliance on strict physical findings or numerical criteria in the diagnosis of telogen effluvium. Each patient's scalp hair has an individual characteristic growth cycle. There are patients who have a very long anagen phase and a small proportion of hair in telogen at any given time. These patients may experience an episode of telogen effluvium but have completely normal physical findings. History alone must guide the physician to the correct diagnosis in these cases.

There should be no areas of total alopecia in a patient with telogen effluvium. Scarring is not present. There also should be no sign of an inflammatory scalp dermatitis. Usually, there are no complaints of body hair loss.

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Causes

Physiologic stress is the cause of telogen effluvium. These inciting factors can be organized into several categories, noted below. Evidence from mouse studies indicates that psychological stress can induce catagen, mainly by effects on neurotransmitters and hormones.[8] In humans, however, the role these effects play in hair loss has not yet been determined. While substance P has been extensively studies in human hair follicles in vitro, in vivo studies have not been performed.[9] In HIV disease,[10] apoptosis may be related to HIV-1 viral protein R.[11] Note the following causes:

  • Acute illness such as febrile illness, severe infection, major surgery, and severe trauma
  • Chronic illness such as malignancy, particularly lymphoproliferative malignancy; and any chronic debilitating illness, such as systemic lupus erythematosus, end-stage renal disease, or liver disease
  • Hormonal changes such as pregnancy and delivery (can affect both mother and child), hypothyroidism, and discontinuation of estrogen-containing medications [12] (see image below)
    Telogen effluvium secondary to hypothyroidism. Telogen effluvium secondary to hypothyroidism.
  • Changes in diet like crash dieting, anorexia, low protein intake, and chronic iron deficiency [13, 14, 15, 16] : A study by Olsen et al sought to determine if iron deficiency played a role in female pattern hair loss. Results indicated that iron deficiency is common in women but is not significantly increased in patients with female patterns of hair loss or chronic telogen effluvium when compared with control subjects. [17]
  • Heavy metals such as selenium, arsenic, and thallium
  • Medications, of which the most frequency cited are beta-blockers, anticoagulants, retinoids (including excess vitamin A), propylthiouracil (induces hypothyroidism), carbamazepine, and immunizations [18, 19, 20]
  • Psychological stress [16]
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Contributor Information and Disclosures
Author

Elizabeth CW Hughes, MD Dermatologist, Group Health Cooperative

Elizabeth CW Hughes, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Leonard Sperling, MD Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References
  1. Sinclair R. Chronic telogen effluvium: a study of 5 patients over 7 years. J Am Acad Dermatol. 2005 Feb. 52(2 Suppl 1):12-6. [Medline].

  2. Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J Am Acad Dermatol. 1996 Dec. 35(6):899-906. [Medline].

  3. Perez-Mora N, Goren A, Velasco C, Bermudez F. Acute telogen effluvium onset event is associated with the presence of female androgenetic alopecia: potential therapeutic implications. Dermatol Ther. 2014 May-Jun. 27(3):159-62. [Medline].

  4. Headington JT. Telogen effluvium. New concepts and review. Arch Dermatol. 1993 Mar. 129(3):356-63. [Medline].

  5. Cartwright T, Endean N, Porter A. Illness perceptions, coping and quality of life in patients with alopecia. Br J Dermatol. 2009 May. 160(5):1034-9. [Medline].

  6. Schmidt S, Fischer TW, Chren MM, Strauss BM, Elsner P. Strategies of coping and quality of life in women with alopecia. Br J Dermatol. 2001 May. 144(5):1038-43. [Medline].

  7. Jain N, Doshi B, Khopkar U. Trichoscopy in alopecias: diagnosis simplified. Int J Trichology. 2013 Oct. 5(4):170-8. [Medline]. [Full Text].

  8. Hadshiew IM, Foitzik K, Arck PC, Paus R. Burden of hair loss: stress and the underestimated psychosocial impact of telogen effluvium and androgenetic alopecia. J Invest Dermatol. 2004 Sep. 123(3):455-7. [Medline].

  9. Peters EM, Liotiri S, Bodo E, et al. Probing the effects of stress mediators on the human hair follicle: substance P holds central position. Am J Pathol. 2007 Dec. 171(6):1872-86. [Medline].

  10. Padovese V, Racalbuto V, Barnabas GA, Morrone A. Operational research on the correlation between skin diseases and HIV infection in Tigray region, Ethiopia. Int J Dermatol. 2015 Oct. 54 (10):1169-74. [Medline].

  11. Barcaui CB, Gonçalves da Silva AM, Sotto MN, Genser B. Stem cell apoptosis in HIV-1 alopecia. J Cutan Pathol. 2006 Oct. 33(10):667-71. [Medline].

  12. Freinkel RK, Freinkel N. Hair growth and alopecia in hypothyroidism. Arch Dermatol. 1972 Sep. 106(3):349-52. [Medline].

  13. Goette DK, Odom RB. Alopecia in crash dieters. JAMA. 1976 Jun 14. 235(24):2622-3. [Medline].

  14. Kantor J, Kessler LJ, Brooks DG, Cotsarelis G. Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol. 2003 Nov. 121(5):985-8. [Medline].

  15. Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006 May. 54(5):824-44. [Medline].

  16. Malkud S. A Hospital-based Study to Determine Causes of Diffuse Hair Loss in Women. J Clin Diagn Res. 2015 Aug. 9 (8):WC01-4. [Medline].

  17. Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. J Am Acad Dermatol. 2010 Dec. 63(6):991-9. [Medline].

  18. Brodin MB. Drug-related alopecia. Dermatol Clin. 1987 Jul. 5(3):571-9. [Medline].

  19. Wise RP, Kiminyo KP, Salive ME. Hair loss after routine immunizations. JAMA. 1997 Oct 8. 278(14):1176-8. [Medline].

  20. Katz KA, Cotsarelis G, Gupta R, Seykora JT. Telogen effluvium associated with the dopamine agonist pramipexole in a 55-year-old woman with Parkinson's disease. J Am Acad Dermatol. 2006 Nov. 55(5 Suppl):S103-4. [Medline].

  21. Tosti A, Piraccini BM, van Neste DJ. Telogen effluvium after allergic contact dermatitis of the scalp. Arch Dermatol. 2001 Feb. 137(2):187-90. [Medline].

  22. Sinclair R, Jolley D, Mallari R, Magee J. The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women. J Am Acad Dermatol. 2004 Aug. 51(2):189-99. [Medline].

  23. Rebora A, Guarrera M, Baldari M, Vecchio F. Distinguishing androgenetic alopecia from chronic telogen effluvium when associated in the same patient: a simple noninvasive method. Arch Dermatol. 2005 Oct. 141(10):1243-5. [Medline].

  24. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol. 2006 Nov. 55(5):799-806. [Medline].

 
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Telogen effluvium secondary to hypothyroidism.
 
 
 
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