hair loss Telogen Effluvium

•  Telogen Effluvium (TE) is a form of non-scarring alopecia characterized by diffuse hair shedding.
•  Telogen Effluvium can occur at any age.
•  TE may be one of the two types:
•  Acute form, if shedding lasts less than 6 months and the onset is relatively sudden.
•  Chronic form, if lasts longer than 6 months. The onset is often insidious  , and it is difficult to identify the causative event.
•  Acute TE can occur in males and females if the cause exists.
•  Chronic Telogen Effluvium has been reported mainly in women.

• Pathophysiology
•  In most people, 5-15% of the hair on the scalp is in telogen phase.
•  TE is triggered when a physiologic stress or hormonal change causes a large number of hairs to enter telogen at one time.
•  Follicles in anagen prematurely enter telogen and are subsequently shed 2–3 months after the occurrence of the cause.
•  Usually no more than 50% of the hair is affected, and hair loss may occur up to 3 months after the event that causes it.
•  Generally, recovery is spontaneous and occurs within 6 months

• Causes
•  Telogen Effluvium has many causes including:
• Pregnancy
•  During pregnancy anagen hairs increase from 84% in the first to 94% in the final trimester.
•  After delivery, follicles enter catagen and then telogen.
•  Increased hair loss may occur 1–4 months after childbirth, and may continue for several months.
•  Full recovery is usual in 4–12 months.
•  Loss is more marked in the frontal and temporal regions, but may be generalized. It is never total.
•  Telogen Effluvium tends to be less severe in subsequent  pregnancies.
• Crash dieting/hypo-proteinemia
•  Acute voluntary starvation in young women must be questioned on taking history.
•  Crash diet of salads and fruits lacking in protein can lead to hair loss.
•  This can be prevented by the addition of a small amount of protein to diet.
• Thyroid influences
•  TE may be sometimes the first or only cutaneous sign of hypothyroidism.

• Iron deficiency
•  Iron deficiency with or without anemia has been reported to be present in as many as 72% of women with TE.
•  There is evidence that the taking of excessive and unnecessary supplements could actually induce telogen effluvium, for example, large amounts of zinc in supplements (> 25 mg/day) may affect iron absorption adversely.
• Major interventions and prolonged anesthesias
•  Blood loss and surgery with prolonged anesthesia may cause telogen effluvium.
• Malignant disease, renal failure, hepatic disease and malabsorption
•  Hodgkin’s disease may present with TE as its first sign.
•  Chronic renal disease can cause scalp hair can become dry, brittle and sparse .
• There may be thinning of body hair, including pubic or axillary hair.
•  Hepatic disease has been reported to be associated with TE since liver is the major site of amino acid inter-conversion. Disturbed liver metabolism of cysteine and methionine may be related to TE.
•  If hair growth retardation is associated with chronic frequent loose pale and bulky stools, malabsorption should be investigated.
•  Diseases of the scalp, such as psoriasis and seborrheic dermatitis, can produceTE.
•  Some medications can cause TE.
• Psychological stress, acute anxiety, and depression
•  Acute anxiety or depression may cause TE but the lack of reports suggests that it is uncommon.
• Fever
•  Fever can cause alopecia 8–10 weeks after the bout.
•  It can be quite severe but hair loss is not total and is usually reversible.
• Symptoms
•  There should be no sign of inflammatory scalp dermatitis.
•  In both acute and chronic TE patients usually only complain about increased hair falling.
•  In both forms of telogen effluvium, hair is lost diffusely from the entire scalp.
•  There should be no areas of total alopecia in a patient with telogen effluvium.
•  Usually, there are no complaints of body hair loss.
•  Metabolic or physiologic stress 1-6 months before the start of the hair shedding should be questioned to detect the presence of TE.
•  In active telogen effluvium, the gentle hair pull test will yield at least 4-6 hairs with each pull. If the patient's active shedding has ceased, the hair pull will be normal.
•  Telogen hairs are identified by a white bulb and the lack of a gelatinous hair sheath.
•  Thyrotropin test is required if any sign or symptom of hypothyroidism is present.
•  Iron deficiency is common in premenopausal women. Evaluation of CBC count, serum iron, iron saturation, and ferritin may be required.
• Treatment
• General considerations
•  Acute Telogen Effluvium is a reactive process, which resolves spontaneously, while chronic Telogen Effluvium is less likely to resolve rapidly.
•  Any reversible cause of hair shedding, such as poor diet, iron deficiency, hypothyroidism, or medication use, should be firstly corrected.
•  Hair transplantation is not an effective treatment for telogen effluvium.

• Lines of treatment
•  Minoxidil
•  Cosmeceuticals
•  Hair supplements
•  Diet
•  The dietary consultation should focus on adequate protein intake, replenishing low iron stores, and obtaining essential nutrients.
•  If the patient takes large doses of vitamin A, this practice should be stopped or the patient should be referred to the physician.
• Patient education
•  Reassurance is appropriate for these patients. Often, the knowledge that the hair loss will not progress to baldness is comforting to the patient.
•  Patient should be informed that reversible causes of hair shedding, such as poor diet, iron deficiency, hypothyroidism, or medication use, should be corrected.
• The patient should be encouraged to style the hair in a way that masks any perceived defects in hair density.