Telogen effluvium is a non-scarring diffuse hair shedding disorder caused by a shift of hair follicles from anagen to telogen, leading to increased daily shedding. It can be acute (≤6 months) or chronic (>6 months). Triggers include physiological/psychological stress, febrile illness (e.g., COVID-19), surgery, postpartum state, nutritional deficiencies (iron), thyroid disease, medications, and crash dieting. Management focuses on identifying and correcting triggers, counseling, and supportive measures; hair typically regrows once the trigger resolves.
Epidemiology
- Common in women; true prevalence unknown due to underdiagnosis.
- Postpartum TE affects many within 2–5 months after delivery.
Pathophysiology
- Insults to the hair cycle precipitate premature termination of anagen and synchronized shedding 2–3 months later.
- Chronic TE may represent persistent triggering, nutritional deficits, or overlap with female pattern hair loss.
Clinical Features
- Diffuse shedding with increased hair on pillow/shower/brush; positive hair pull test (≥6 hairs from several scalp sites).
- Scalp appears normal; part width may seem wider due to reduced volume but without miniaturization pattern.
- Onset typically 2–3 months after trigger; postpartum TE aligns with hormonal shifts after delivery.
Differential Diagnosis
- AGA (pattern thinning, miniaturization), alopecia areata incognita (diffuse shedding with exclamation hairs), anagen effluvium (chemotherapy), traction alopecia, scalp psoriasis/seb derm if inflammatory.
Workup
- History to identify triggers 2–4 months prior (illness, stress, surgery, diet, meds).
- Labs guided by history:
- Ferritin (target >30–70 ng/mL in hair loss patients; some aim >70), CBC.
- TSH (± free T4), vitamin D.
- Consider zinc, B12 if risk factors.
- Trichoscopy: normal shafts without significant miniaturization; occasional yellow dots in AAI.
- Consider biopsy if diagnosis unclear or chronic shedding with suspicion of AGA overlap.
Management
- Address triggers and deficiencies
- Treat thyroid disease; replenish iron to targets; optimize nutrition and protein intake.
- Review medications (retinoids, beta-blockers, anticoagulants, isotretinoin, valproate) and modify if possible.
- Counseling and expectations
- Reassure that regrowth follows within months after trigger control; density normalizes over 6–12 months in acute TE.
- Explain lag time between trigger and shedding; normalize the experience to reduce anxiety-driven hair practices.
- Supportive therapies
- Topical minoxidil can shorten TE duration and support regrowth, especially if AGA overlap is suspected.
- Gentle hair care; avoid tight styles, harsh treatments; volumizing strategies.
- Consider low-dose oral minoxidil in chronic TE with overlap (off-label) after excluding contraindications.
- Chronic TE
- Search for ongoing triggers (nutritional deficits, chronic systemic disease, medications).
- Evaluate for overlapping AGA in women with persistent part widening; combination therapy may be needed.
- Postpartum TE
- Expect spontaneous resolution within 6–12 months; ensure iron sufficiency; minoxidil optional if bothersome and not breastfeeding or after risk discussion.
Prognosis
- Acute TE resolves with trigger removal; chronic TE may remit but can persist if triggers remain.
- Excellent prognosis overall; patient education is key to adherence and reduced distress.
References (recent guidelines and key reviews)
- Evidence-based reviews on TE diagnosis and management, 2021–2024.
- Post-COVID and postpartum TE studies, 2021–2024.
- Iron/thyroid and nutritional factors in hair loss, 2022–2024.