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Telogen Effluvium
Elizabeth C. Hughes; Dahlia Saleh.
Author Information
Last Update: June 8, 2021.
Continuing Education Activity
Telogen effluvium is a form of nonscarring alopecia characterized by diffuse, often acute hair
shedding. Telogen effluvium is a reactive process, triggered by metabolic stress, hormonal
changes, or medications. Common triggering events are acute febrile illness, severe infection,
major surgery, severe trauma, postpartum hormonal changes, particularly a decrease in estrogen,
hypothyroidism, discontinuing estrogen-containing medication, crash dieting, low protein intake,
heavy metal ingestion, and iron deficiency. Many medications have been linked to telogen
effluvium, but the most common are beta-blockers, retinoids, including excess vitamin A,
anticoagulants, propylthiouracil, carbamazepine, and immunizations. This activity reviews
telogen effluvium and highlights the role of the interprofessional team in the recognition and
management of patients affected by it.
Objectives:
Describe the causes of telogen effluvium.
Identify the testing that should be done if telogen effluvium is suspected.
Outline the treatment strategies for a patient with telogen effluvium.
Review the importance of enhancing care coordination among the interprofessional team
to ensure proper evaluation and management of telogen effluvium.
Access free multiple choice questions on this topic.
Introduction
Telogen effluvium is a form of nonscarring alopecia characterized by diffuse, often acute hair
shedding.[1][2][3][4][5] Another form that is chronic with a more insidious onset also
exists. Telogen effluvium is excessive shedding of resting or telogen hair after some metabolic
stress, hormonal changes, or medication. Telogen hair is also known as club hair due to the shape
of the root. In a normal healthy person's scalp, about 85% are anagen hair and 15% are telogen
hair. Anagen hair are actively growing hair while telogen hair are resting hair. A few hairs may
also be in catagen. A hair follicle usually grows anagen hair for almost four years, then rests for
about four months. A new anagen hair begins to grow under the resting telogen hair and pushes it
out. If there is some kind of stress to the body it can cause 70% of anagen hair to precipitate into
the telogen phase thus causing hair loss.
Etiology
Telogen effluvium is a reactive process, triggered by metabolic stress, hormonal changes, or
medications. Common triggering events are acute febrile illness; severe infection; major surgery;
severe trauma; postpartum hormonal changes, particularly a decrease in estrogen;
hypothyroidism; discontinuing estrogen-containing medication; crash dieting; low protein intake;
heavy metal ingestion; and iron deficiency. Many medications have been linked to telogen
effluvium, but the most common are beta-blockers, retinoids (including excess vitamin A),
anticoagulants, propylthiouracil, carbamazepine, and immunizations.
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17/07/2022 12:39 Telogen Effluvium - StatPearls - NCBI Bookshelf
Epidemiology
Telogen effluvium can occur in people of any age, any gender, and any racial background. The
exact prevalence of telogen effluvium is not known, but it is considered to be quite common. A
large percentage of adults experience an episode of telogen effluvium at some point. Telogen
effluvium can occur in either sex, though women have a greater tendency to experience this
condition because of postpartum hormonal changes. Also, women are more disturbed by hair
shedding than men and are therefore more likely to seek medical attention. [6][7][8][9]
Pathophysiology
Telogen effluvium is triggered when physiologic stress causes a large number of hairs in the
growing phase of the hair cycle (anagen) to abruptly enter the resting phase (telogen). The
growth of the telogen hairs ceases for 1 to 6 months (on average 3 months), though this cessation
of growth is not noticed by the patient. When the hairs reenter the growth phase (anagen), the
hairs which had been suspended in the resting phase (telogen) are extruded from the follicle, and
hair shedding is observed.
Histopathology
Histologic findings in telogen effluvium are best seen in transverse sections of a punch biopsy.
The number and density of hair follicles are usually normal, but there is an increased
percentage of the hair follicles that are in the catagen or the telogen phase.
If 25% of the follicles are in the telogen phase, the diagnosis of telogen effluvium is
confirmed.
The percentage of telogen hair should not typically be higher than 50%.
History and Physical
Patients will report hair shedding, usually without other symptoms, with a relatively abrupt
onset. By definition, in acute telogen effluvium, shedding lasts less than six months; often the
period of shedding is much shorter. A careful history will identify a causative event (see etiology
section) occurring approximately three months before the onset of the shedding (range from 1 to
6 months). Quite often the patient has fully recovered from the acute illness and fails to see the
connection between the illness with the hair loss.
The physical examination is grossly normal, as it is difficult for the casual observer to appreciate
the loss of hair volume. It can be helpful to compare the patient's current appearance with old
pictures. If the patient presents during the acute shedding, a gentle pull test yields at least four
hairs removed with each pull. However, if the patient presents after the acute shedding has
passed, the pull test may be normal. Careful examination of the scalp will show an increased
percentage of short anagen hairs growing close to the scalp.
Evaluation
Usually, a careful history and physical examination are sufficient to diagnose telogen effluvium.
Biopsy, if taken during the acute shedding phase (when the pull test is positive), can confirm an
increase in the percentage of telogen hairs. If there is a concern for a hormonal condition (such as
hypothyroidism), a chronic metabolic illness, or iron deficiency, testing for these conditions is
indicated.[10][11]
Laboratory Testing
Chronic telogen effluvium sometimes has a metabolic cause.
Hypothyroidism
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If symptoms of hypothyroidism are present, a thyrotropin test is warranted
Iron Deficiency
Iron deficiency should be evaluated with a complete blood count, serum iron, iron
saturation, and ferritin.
Blood is more important to survival than hair, so the body will shed hair before red cell
indices become microcytic.
Ferritin behaves as an acute-phase reactant, and inflammation can result in normal ferritin
levels in an individual who is iron deficient.
Low ferritin confirms iron deficiency; a normal ferritin level does not exclude iron
deficiency.
Iron saturation is the most sensitive indicator of iron deficiency.
Syphilis
If syphilis is considered a cause, a rapid plasma reagin or VDRL test should be performed.
Biopsy
Scalp biopsy is the most useful test to confirm the diagnosis, but it is seldom necessary if
gentle hair pull produces numerous telogen hair.
Telogen hair can be identified by a white bulb and no gelatinous hair sheath.
If a patient is unwilling to allow a scalp biopsy, serial hair collections can be obtained.
The patient should be instructed to collect all shedding hair in a 24-hour period. The
patient should avoid washing the hair during the collection. This process should be
repeated every week for a total of three or four collections.
Collecting 100 hairs or more hairs in a 24-hour period suggests telogen effluvium. If the
collections are performed over several weeks while the telogen effluvium is improving, the
number of hairs collected may decrease.
Treatment / Management
Acute telogen effluvium is a self-limited condition. If the causative event is identified by history
and has been adequately treated, no further treatment is required. If a hormonal or dietary
imbalance or metabolic illness is present, hair growth will return after these factors are corrected.
If a medication is the cause of the shedding, hair growth will restart after the medication is
withdrawn.
Hair transplantation has no role in the treatment of telogen effluvium.
While topical minoxidil has not been proven to promote recovery of hair in telogen effluvium, it
has theoretical benefits. Patients who wish to take an active role in their treatment may choose to
use minoxidil.
Differential Diagnosis
The differential diagnoses of telogen effluvium include:
Alopecia areata
Anagen effluvium
Androgenetic alopecia
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17/07/2022 12:39 Telogen Effluvium - StatPearls - NCBI Bookshelf
Scarring alopecia
Syphilis
Trichotillomania
Prognosis
Morbidity is generally limited to mild cosmetic changes which are mild. Mortality has not been
reported.
Telogen effluvium has a major impact on those affected by the disease.
The prognosis for a good recovery of hair density occurs in acute telogen effluvium.
A good cosmetic outcome is also expected in chronic telogen effluvium, even if the hair
shedding continues.
Complications
Telogen effluvium is a benign and spontaneously reversible condition, there are no complications
associated with it.
Deterrence and Patient Education
It may take up to six months for hair growth to restart, and even longer for the growth to be
appreciable by the patient. Patients often require the reassurance of the normal recovery of their
hair while the hair reenters anagen and grows normally. Patients may also worry that normal
grooming of their hair worsens the hair shedding. Patients should be reassured that their hair is
normal and that they can wash and style their hair as usual.
Enhancing Healthcare Team Outcomes
The diagnosis and management of hair loss are with an interprofessional team that includes a
dermatologist, primary care provider, nurse practitioner, and internist. One type of hair loss is
telogen effluvium, which is a form of nonscarring alopecia characterized by diffuse, often acute
hair shedding. In most cases, no cause is ever found. In any case, patients need to be educated
that the condition is self-limiting. There is no need to prescribe hair growth medications or refer
the patient for a hair transplant. The hair growth will return but it may take a few months or even
a year. For most patients, the outcome is good.[12][13](Level V)
Review Questions
Access free multiple choice questions on this topic.
Comment on this article.
References
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Treatment of telogen effluvium using a dietary supplement containing Boswellia serrata,
Curcuma longa, and Vitis vinifera: Results of an observational study. Dermatol Ther. 2019
May;32(3):e12842. [PubMed: 30693615]
2. Sari Aslani F, Heidari Esfahani M, Sepaskhah M. Non-scarring Alopecias in Iranian Patients:
A Histopathological Study With Hair Counts. Iran J Pathol. 2018 Summer;13(3):317-324.
[PMC free article: PMC6322526] [PubMed: 30636954]
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wrong in their daily life? Skin Res Technol. 2019 May;25(3):367-374. [PubMed: 30614076]
4. Stoehr JR, Choi JN, Colavincenzo M, Vanderweil S. Off-Label Use of Topical Minoxidil in
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Alopecia: A Review. Am J Clin Dermatol. 2019 Apr;20(2):237-250. [PubMed: 30604379]
5. Daly T, Daly K. Telogen Effluvium With Dysesthesia (TED) Has Lower B12 Levels and
May Respond to B12 Supplementation. J Drugs Dermatol. 2018 Nov 01;17(11):1236-1240.
[PubMed: 30500148]
6. Sant'Anna Addor FA, Donato LC, Melo CSA. Comparative evaluation between two
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29948959]
8. Saleh D, Nassereddin A, Cook C. StatPearls [Internet]. StatPearls Publishing; Treasure Island
(FL): Aug 12, 2021. Anagen Effluvium. [PubMed: 29493918]
9. Motosko CC, Bieber AK, Pomeranz MK, Stein JA, Martires KJ. Physiologic changes of
pregnancy: A review of the literature. Int J Womens Dermatol. 2017 Dec;3(4):219-224.
[PMC free article: PMC5715231] [PubMed: 29234716]
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free article: PMC4606321] [PubMed: 26500992]
12. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss
patient: part I. History and clinical examination. J Am Acad Dermatol. 2014
Sep;71(3):415.e1-415.e15. [PubMed: 25128118]
13. Hamm H. [Acquired alopecia in childhood]. Hautarzt. 2013 May;64(5):371-9; quiz 380-1.
[PubMed: 23571647]
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