Aggressive telogen effluvium in males: A common misdiagnosis of androgenetic alopecia

Question

I am a 23 year old male and have been diagnosed with fairly aggressive case of telogen effluvium. It started at age 21 and does not seem to be improving. I have been using biotin supplements recently but they too don’t seem to be helping. I am healthy and take no medications or drugs. What are your recommendations to stop the shedding?

Answer

Thanks for the great question. I think the most important consideration for you is whether, in fact, you have been given the correct diagnosis. I would need to see photos and know everything about your story and recent blood test results to tell you what diagnosis you have. However, androgenetic alopecia (male balding) needs to be considered in your case. In fact, I would state it even more boldly: in a situation like this with a 2 year history of hair loss in a 23 year old male, we need to prove that you don’t have androgenetic alopecia before moving any further. Once we deal with that, we can move on.

Far too many cases I see that are diagnosed as being telogen effluvium are misdiagnoses. Does telogen effluvium exist? Of course! In fact it is a common cause of shedding in patients with hair loss. Is 2 years of telogen effluvium common in a 23 year old healthy male? No, it most certainly is not.


Telogen effluvium happens from a variety of reasons. These include low iron levels, thyroid problems, stress, medications and illness. In most cases, they are temporary and once the trigger is identified and stopped or fixed- hair grows back. In your case we need to look for a trigger but the reality is that after two years of shedding in a healthy male, there may not be one. It’s still important to search.

Most cases of aggressive telogen effluvium in young males are in fact cases of aggressive androgenetic alopecia instead. It is commonly forgotten that androgenetic alopecia in males can be associated with shedding. In young males with strong genetics that is driving the balding process, shedding can be quite significant.

A male with shedding needs of course to have a full evaluation. One needs to know your history in precise detail. Underlying health conditions, medications, recreational drugs, sexual transmitted diseases, diet, eating disorders and psychological issues all need to be considered.

Young males with shedding need blood tests for CBC, iron (ferritin), thyroid (TSH) and vitamin D (25 hydroxyvitamin D). A hormonal profile is not useful for most males. Other tests could be relevant on a case by case basis including zinc, ANA, ESR and tests for sexually transmitted diseases but usually these are unnecessary.

If there is any doubt that exists, a scalp biopsy can be helpful in proving or disproving whether a patient has androgenetic alopecia - especially when so called “horizontal sections” are used by the pathology lab. Horizontal sections allow the pathologist to determine accurately something called the terminal to vellus (T:V) ratio. A terminal to vellus ratio of less than 4:1 indicates a high likelihood of androgenetic alopecia.

In summary, for a young male a diagnosis of “aggressive telogen effluvium” one must be absolutely certain that a diagnosis of androgenetic alopecia is not being missed.