Chronic Telogen Effluvium (CTE): A Closer Look at the Classic Whiting Study

The 1996 Whiting Study

The field of hair loss has its classic papers. These are papers that stand the test of time and influences the research that comes in the decades that follow. Dr David Whiting did some pioneering work in understanding exactly what chronic telogen effluvium (CTE) is what it is not. Whiting described CTE as a condition which usually affects 30- to 60-year-old women, starts abruptly with or without any sort of “trigger”. Whiting showed that CTE had a long fluctuating course.


Dr. Whiting’s 1996 paper on chronic telogen effluvium effluvium (CTE) is one of these classics. Dr Whiting set out to determine distinctive clinical and pathologic criteria for the diagnosis of CTE. He also wanted to determine how biopsies of CTE differs from biopsies of androgenetic alopecia (AGA). To do so, Whiting studied biopsy findings in 355 patients with CTE. Results were compared to 412 patients with androgenetic alopecia (AGA) and 22 control subjects without hair loss. For patients without hair loss, the average number of hairs in the biopsy was 40, the terminal/velluslike (T:V) hair ratio was 7:1, 93.5% of the terminal hairs were in anagen, and 6.5% were in telogen. For patients with CTE the average number of hairs was 39, the terminal/velluslike (T:V) hair ratio was 9:1, 89% of the terminal hairs were in anagen, and 11% were in telogen. In AGA the average number of hairs was 35, the T:V ratio was 1.9:1, 83.2% of hairs were anagen and 16.8% were telogen phase hairs. Interestingly, significant degrees of inflammation and fibrosis were present in only 10% to 12% of cases of CTE and normal controls, but occurred in 37% of cases of AGA.


This was a classic study and all providers of car to hair loss patients should take the time to understand this study. Evaluation of the T:V ratio in biopsies can help distinguish CTE from AGA. The ratio is 8:1 or higher in CTE and less than 4:1 in AGA. The proportion of hairs in telogen phase was 50% higher in AGA than TE.


Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J Am Acad Dermatol 1996

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

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