Hair Blogs

QUESTION OF HAIR BLOGS

Filtering by Category: CTE


Does hair density always come back in a telogen effluvium?

Does hair density always come back after a telogen effluvium?

te-sequelae


One of my favorite hair loss topics centers around what happens to a person’s hair density 9 months after a telogen effluvium. Broadly speaking, this is topic is called the “sequelae of telogen effluvium.”

Before we begin, I will remind you that Telogen effluvium (TE) is a hair shedding condition whereby a patient notices more hair coming out of the scalp than normal on a daily basis.

Most would say that 6-9 months after a TE, the hair density improves back to normal. This is true only if all the correct “triggers” of the TE can be found. Many times a trigger can’t be found and many times even if a patient or physician think they know the trigger, it’s not actually the trigger. For example, many patients who think their low vitamin D or low iron levels are the sole cause of their TE may find the shedding does not improve simply by supplementing vitamin D and iron. The reality is that unless the exact trigger or triggers can be found it is likely the shedding will not stop. Typical triggers include thyroid problems, dietary issues, low iron (sometimes), stress, medications, scalp diseases (seborrheic dermatitis) and over 700 internal conditions (infection, joint disease, lupus, cancer).

But two other “sequelae” can occur including the development of chronic shedding and coming to be diagnosed with another completely separate hair loss condition.


 
Sequelae 1: Chronic Shedding

For some patients, despite fixing all the suspected triggers, the shedding persists for more than 6-9 months and enters what we call “chronic shedding.” For some patients, the shedding eventually just stops and density returns to normal. This can happen without any particularly good reason and is very exciting for patients when it does occur. For other patients with chronic shedding, a trigger is eventually found and addressing that trigger causes the shedding to improve. This might be a patient who discovers a chronic underlying medical condition and addresses it. Hundreds of such examples exist. But some patients continue to shed for many many years despite their being NO obvious trigger and despite their health being very good. We call this chronic idiopathic telogen effluvium or simple chronic telogen effluvium (CTE). In my mind CTE is a specific condition when no obvious ongoing trigger is present.
 

Sequelae 2: Development of a Second Condition

Finally, one additional sequelae needs to be considered - and that is the possibility that hair density does not return to normal because a second hair loss condition develops. It's not that the shedding condition caused the second condition but rather that the second condition was there all along. This is more common than appreciated. For some individuals with a genetic predisposition to androgenetic alopecia, chronic shedding can speed up the development of balding. This is often referred to by a bizarre phrase whereby you might hear it said that chronic shedding “precipitates” androgenetic alopecia. I prefer to refer to the phenomenon in our clinic as “AFMPS” or accelerated follicular miniaturization from prolonged shedding because it makes more sense than using the word “precipitation.” But the concepts are the same: patient with chronic shedding who are destined to develop male and female balding in the more distant future may find that they develop androgenetic balding a bit sooner. We see this commonly after various effluviums. Why do some women after months and months of shedding find their density does not return despite fixing the suspected trigger? AFMPS or the unexpected arrival of genetic hair loss. This concept is too often forgotten or not understood.

One must also keep in mind that in addition to genetic hair loss, other conditions can rarely also declare themselves after a patient develop shedding. Chronic shedding diagnosed as a TE may rarely be the earliest stages of a scarring alopecia or the earliest stages of alopecia areata (diffuse alopecia areata or alopecia areata incognito). A physician must always keep these entities in the back of his or her mind when evaluating a patient with chronic shedding.

 

Summary

In summary, telogen effluvium can either be uncomplicated or complicated. We can’t tell patients that their shedding will stop in a few months and everything will return to normal. We can of course hope for it. Fortunately most patients do follow an uncomplicated story of shedding. Shedding —-> fix trigger(s) ——> shedding stops ——> hair grows back. But this is not the case for all.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
4 Comments

The Modified Hair Wash Test (MHWT)

A closer look at the MHWT for Differentiating CTE and AGA

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized by dermatologist mainly because of lack of familiarity and exposure. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The patient may perform this test at home. 

 

Performing the MHWT

To perform the MHWT, a patient is instructed to avoid shampooing the hair for 5 days before the date of set test date. On the day of the test, the sink is covered with a gauze. The hair is then shampooed thoroughly and rinsed. The hairs trapped in the gauze are collected counted and divided into hairs less than 3 cm and more than 5 cm.

 

Interpreting the MHWT

Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having AGA; Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
12 Comments

Acute and Chronic Telogen Effluvium: How do they differ?

Acute and Chronic TE

There are two common types of telogen effluviums. Both lead to increased daily shedding.

Acute TE

CTE 620

Acute telogen effluvium (ATE) is associated with some type of "trigger" that then leads to massive shedding. Correction of the "trigger" can lead to resolution of the shedding and a return in density back to normal in 9-12 months. Common triggers include thyroid problems, dieting, medications, high stress, low iron and illness in the body.

Chronic TE

"Chronic" telogen effluvium (CTE) is often misdiagnosed and often mixed up with acute telogen effluvium. Chronic TE is associated with shedding too. The actual amount of hair shed is typically less than the worst possible cases of acute TE. CTE can be associated with a "trigger" but less commonly than acute TE. CTE does improve but then shedding occurs again - sometimes in a very unpredictable manner. Resolution can occur but it may take many years. 
This graph shows how density typically changes over time in patients with acute and chronic effluviums.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
6 Comments

Density Changes in CTE vs AGA over Time

Chronic Telogen Effluvium: How does density change over time?

Chronic Telogen Effluvium (CTE) and Androgenetic alopecia (AGA) are both commonly encountered diagnoses in women age 40-70 years. They are however, very different conditions. 

CTE-density

AGA: Androgenetic Alopecia

AGA presents with hair thinning and sometimes increased daily shedding as well. The loss of hair is sometimes just frontal in location or the crown but can be diffuse (all over). A key to the diagnosis is recognition of the progressive reduction in the caliber (diameter) of hairs. 

 

CTE: Chronic Telogen Efflvuium


Patients with CTE can appear to have a similar story. Many have a sudden onset of shedding. The shedding is diffuse. The temples may be particularly affected with reduced density to a much more significant degree than seen in AGA. Reduced hair caliber (miniaturization) is not a feature of CTE. CTE has periods where shedding appears to slow considerably or even stop. When one follows these conditions for many years there is a realization of another important difference: Density in CTE reduces initially but then plateaus and does not reduce further. Density in AGA continues to drop off over time. These points are illustrated in the graph.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

Chronic Telogen Effluvium (CTE)

Misdiagnoses common with CTE

CTE

Chronic telogen effluvium (CTE) is an interesting and frequently misdiagnosed hair shedding condition. Many patients with androgenetic alopecia, acute telogen effluvium and even alopecia areata are diagnosed as having chronic telogen effluvium.

 

How does CTE present?


Most patients with true CTE are 40-65 and present with sudden onset of increased hair shedding that fluctuates in intensity. Some days there is alot of shedding. Some days very little. Many patients have scalp pain (trichodynia) which may correlate with the shedding episodes. Patients with CTE often appear to have good hair density to an outsider which makes the condition frustrating for the patient. A careful history and exam can confirm the diagnosis in many cases. Follicular miniaturization is not a feature unless genetic hair loss is present too. A hair collection or scalp biopsy is useful in more challenging cases.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
3 Comments

Can stress cause hair loss?

Stress and Hair Loss

It is possible that stress can cause hair loss, although it does not happen to everyone. High levels of stress can trigger an increased amount of hair shedding. The hair shedding is typically experienced 2-3 months later at its peak but is highly variable. Some shed one month later and some 3. Even the same person can experience great variability in how they shed. One stressful event triggers shedding 4 weeks later yet another stressor causes a delay of 3 months.

The diagram above shows a typical stress - shedding response. For some, a high level intense stress in February will trigger a shed sometime starting in April and peaking in May/June. For reasons that are not clear, this stress-shedding cycle does not occur in everyone.

Stress may play a role in other hair conditions. In my opinion, high stress may accelerate androgenetic alopecia a slight bit. Stress can make scarring alopecia much more itchier. I do believe stress has a major role in frontal fibrosing alopecia- with many patients reporting extremely high stress at the time of disease onset.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

Standardized Hair Collections

Identifying AGA and TE

Telogen effluvium (TE) and androgenetic alopecia (AGA) are common, especially among women. There are many ways to differentiate a shedding disorder (TE) from AGA - and some women have both. 

A clinical examination of the scalp, a biopsy and a so called "hair collection" are three methods to evaluate a patient's diagnosis. Exactly which one I use depends on the specific clinical situation. Certainly not everyone with hair loss needs a biopsy and not everyone needs to perform a hair collection.

There are many different ways to perform a hair collection. Rebora studied the use of the 5 day hair collection, where shampooed hairs are trapped on a gauze 5 days after shampooing. The collected hairs are divided into three groups: telogen vellus hairs (less than 3 cm), intermediate hairs (3-5 cm) and long hairs (more than 5 cm). The presence of more than 10 % non broken hairs 3 cm or less is suggestive of the diagnosis of androgenetic alopecia (AGA).

 

Reference


Distinguishing androgenetic alopecia from chronic telogen effluvium when associated in the same patient: a simple noninvasive method.
Rebora A, et al. Arch Dermatol. 2005.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

Hair Shedding and the "Exogen" Phase

Exogen Phase

There are various phases of the hair growth cycle that you may have heard of such as anagen, catagen and telogen. Anagen is the growing phase. Catagen is the transitional phase. Telogen is the resting phase where hairs stop growing. At the end of the telogen phase, hairs shed from the body- and end up in our brushes, combs, and shower drains.

So what is the "exogen phase"? Well, for years it was thought that once a hair is ready to be shed, it simply leaves that scalp when a hair underneath pushes it out. We know now that is untrue. A hair can of course leave the scalp when enough tug is given to it. However, the departure of a hair from the scalp is now recognized to be a highly regulated process which is known as "exogen." Therefore, hairs are not simply pushed out of the scalp - the process is tightly regulated.

This picture shows the scalp of a patient with a telogen effluvium (hair shedding disorder). Upright regrowing hairs (URG) are seen. In addition, a telogen hair (also called a club hair) can also be seen. This hair has officially been shed from the patient's scalp. It is nested amongst the existing hair. At the time of the next patient's next shampooing or brushing it will likely be removed completely from the scalp.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

What kind of hairs are going down my drain after shampooing?

Hair Shedding: What am I seeing?

What kind of hairs typically go down the drain after shampooing one's scalp? Well, in nearly everyone these are hairs known as "telogen hairs."

Telogen hairs are hairs that have a long history. They were previously tightly rooted in the scalp and had spent many years growing (at which point they were called anagen hairs). But after years of growing without even a moment of rest, anagen hairs retire and become known as telogen hairs - and then drop out of the scalp. Telogen hairs lack a root sheath around the ends.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

The Pull Test

What really is normal?

The Hair Pull Test: 3 is abnormal

Telogen effluvium is a form of hair loss where patients experience increased daily hair shedding. Instead of losing 40 or 50 hairs per day, patients with “TE” lose 80 to up to 600 hairs per day. A ‘pull test’ has traditionally been one of the methods that hair specialists are taught to perform when examining the scalp. To perform the test, 60 hairs are lightly grasped between the thumb and index finger and gently pulled upwards. Removal of more than 10 % of the hairs in the bundle (i.e more than 6 hairs) has been traditionally viewed as a positive pull test. 


McDonald and colleagues from Ottawa, Canada performed a study revisiting this issues of what exactly constitutes a normal pull test and what limits should be set for abnormal. They studied 181 otherwise healthy individuals. The authors showed that for the vast majority of individuals, a pull test of 60 hairs extracts 0,1 or 2 hairs (97 % or more have 2 or less). The average was 0.44 hairs indicating that many individuals have no hairs removed. Interestingly, the date the patient last washed their hair, did not influence the pull test result nor did the frequency of brushing the hair. 
This is one of my favourite studies of the year. It is simple and elegant and answers a lot important questions. I have long abandoned the “6 hair rule” for the pull test, and frequently have told the dermatology residents and trainees that work with me that even a few hairs coming out is abnormal. I’m grateful for this well conducted study and it has renewed my interest in the pull test.
 



Reference


McDonald et al. Hair pull test: Evidence-based update and revision of guidelines. Journal of the American Academy of Dermatology 2017; 76: 472


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

Blogs by Topic





Share This
-->