eMedicine Specialties > Dermatology > Diseases of the Adnexa

Telogen Effluvium: Differential Diagnoses & Workup

Author: Elizabeth CW Hughes, MD, Dermatologist, Group Health Cooperative
Contributor Information and Disclosures

Updated: Mar 27, 2009

Differential Diagnoses

Alopecia Areata
Androgenetic Alopecia
Syphilis
Trichotillomania

Other Problems to Be Considered

Acquired hair breakage from grooming practices
Anagen effluvium

Workup

Laboratory Studies

  • Laboratory studies are of little use in the diagnosis of telogen effluvium if there is clear history of an inciting event. Scalp biopsy is the most useful test to confirm the diagnosis, although this is seldom necessary if the history is characteristic and a gentle hair pull produces numerous telogen hairs. Telogen hairs are identified by a white bulb and the lack of a gelatinous hair sheath.
  • If a biopsy is performed, some authors advocate taking three 4-mm punch biopsy specimens, all imbedded horizontally. This method provides a generous sample for determining anagen-to-telogen and terminal-to-vellus ratios and leads to greater diagnostic accuracy.15
  • Chronic telogen effluvium may have a metabolic cause. Testing should be directed toward causes that are common and correctable. If any sign or symptom of hypothyroidism is present, a thyrotropin test is warranted. Iron deficiency is common in premenopausal women. Evaluation of CBC count, serum iron, iron saturation, and ferritin may be warranted. Note that CBC count results may be completely normal in women with mild iron deficiency and hair loss, particularly in women older than 40 years. Blood is more essential than hair, and the body will shed hair before red cell indices become microcytic. Also, note that ferritin behaves as an acute phase reactant. Inflammation can produce normal ferritin levels in an individual who is iron deficient. Although a low ferritin is proof of iron deficiency, a normal ferritin level does not exclude iron deficiency. Some experts in the field regard iron saturation as the most sensitive indicator of iron deficiency.
  • Occasionally, screening for renal and hepatic enzymes may detect a systemic cause of hair shedding. If syphilis is considered as a cause of hair loss, a rapid plasma reagin or Venereal Disease Research Laboratory test should be preformed.

Other Tests

  • If a patient is unwilling to undergo a scalp biopsy but would like confirmation of the diagnosis, serial hair collections may be obtained. This process can educate the patient in the normal hair cycle and can confirm the spontaneous resolution of the process.
  • The patient should be instructed to collect all hairs shed in a 24-hour period. The patient should not shampoo the hair during the day of collection. This process should be repeated every week or every other week, for a total of 3 or 4 collections.
  • Collections totaling 100 hairs or more in a given 24-hour period are indicative of ongoing telogen effluvium. If the collections are performed over several weeks while the telogen effluvium is resolving, the number of hairs collected each time should decrease. This finding can be very comforting to the patient.
  • An alternate method of hair collection has been proposed by Rebora et al. According to this method, the patient collects hair during shampooing and the physician both counts and measures the length of these hairs. This method has the advantage of being able to detect and differentiate between telogen effluvium and androgenetic alopecia, even when the 2 conditions occur in the same individual.16 The disadvantage to this method is that it cannot be used in patients who have short hair (<3 cm). Additionally, the counting and measuring procedure is very labor intensive, which limits its practicality in normal clinical practice.
  • Ross et al report on the successful use of videodermoscopy in the diagnosis of hair and scalp disorders.17

Histologic Findings

Histologic findings in telogen effluvium are subtle and are most easily seen on transverse sections of a punch biopsy. The number and density of hair follicles is normal, but an increased percentage of the hair follicles are in telogen or catagen phase. If more than 25% of the follicles are in telogen phase, the diagnosis is confirmed. The percentage of telogen hairs generally should not be higher than 50%.

More on Telogen Effluvium

Overview: Telogen Effluvium
Differential Diagnoses & Workup: Telogen Effluvium
Treatment & Medication: Telogen Effluvium
Follow-up: Telogen Effluvium
Multimedia: Telogen Effluvium
References
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References

  1. Sinclair R. Chronic telogen effluvium: a study of 5 patients over 7 years. J Am Acad Dermatol. Feb 2005;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. Dec 1996;35(6):899-906. [Medline].

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

  4. 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. Sep 2004;123(3):455-7. [Medline].

  5. 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. Dec 2007;171(6):1872-86. [Medline].

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

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

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

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

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

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

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

  13. 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. Nov 2006;55(5 Suppl):S103-4. [Medline].

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

  15. 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. Aug 2004;51(2):189-99. [Medline].

  16. 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. Oct 2005;141(10):1243-5. [Medline].

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

  18. Camacho F. Alopecias due to telogen effluvium. In: Camacho F, Montagna W, eds. Trichology: Diseases of the Pilosebaceous Follicle. Madrid, Spain: Aula Medica Group; 1993:403-10.

  19. Kligman AM. Pathologic dynamics of human hair loss. I. Telogen effuvium. Arch Dermatol. Feb 1961;83:175-98. [Medline].

  20. Rushton DH. Management of hair loss in women. Dermatol Clin. Jan 1993;11(1):47-53. [Medline].

  21. Rushton DH, Ramsay ID, James KC, Norris MJ, Gilkes JJ. Biochemical and trichological characterization of diffuse alopecia in women. Br J Dermatol. Aug 1990;123(2):187-97. [Medline].

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Further Reading

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Keywords

telogen effluvium, chronic telogen effluvium, nonscarring alopecia, alopecia, hair loss, acute hair loss, non-scarring alopecia, balding

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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 and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

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, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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