Telogen Effluvium: Am I going to get my hair back after telogen effluvium?

A Closer Look at the Chances of Hair Returning Fully After Telogen Effluvium

There is a lot of misinformation, myths, misconceptions surrounding telogen effluvium. So I’d like to review several important issues today. Telogen effluvium seems so simple at first glance - and that’s the first mistake people make when approaching this condition.

What is telogen effluvium?

Telogen effluvium is a hair shedding condition. Patients experienced higher than normal amount of hair shedding and typically this occurs 2-12 weeks after a trigger. There are many mechanisms of telogen effluvium but the most common mechanism (called immediate anagen release) is associated with shedding 2-3 months after the trigger. Other mechanisms exist too.

A variety of triggers cause hair to shed. There are 100’s of them. Fortunately, the most common ones can be remembered by a fairly simple list and include: stress, low iron levels, thyroid and endocrine problems, medications, crash diets, weight loss, medications, infections, fever and internal illness inside the body.

How does on set out to identify the trigger?

Step1: Confirm that you really have the right diagnosis

The goal of helping a patient with telogen effluvium is first and foremost to confirm that the patient has telogen effluvium and not a mimicking condition. That’s where alot of people go wrong. Many conditions cause shedding and make it look like a patient has telogen effluvium. Androgenetic alopecia (male and female pattern hair loss), alopecia areata incognito and scarring alopecias are famous for this. The early stages of androgenetic alopecia, alopecia areata incognito, and scarring alopecia all give shedding. If you don’t know how do properly identify these conditions, The diagnosis will be very easily missed. Sometimes, i’s tough to diagnosis androgenetic alopecia and scarring alopecia in the very early stages.

Step 2: If the Diagnosis is Telogen Effluvium, then Search, Search and Search more (and more) for the Trigger of the Shedding.

The goal that we need to have in mind at all times when evaluating a patient with telogen effluvium is finding the trigger. Not just what we think the trigger is but what we confidently know the trigger is. To find the triggers, we need to review the patient’s full story, including stresses, medications, diets, illnesses, weight loss, fevers that have occurred in the months leading up to the hair loss. Blood tests are mandatory for anyone with presumed telogen effluvium including blood tests for CBC, ferritin (iron test), TSH (thyroid test). An additional 2 to 20 tests might also be needed depending on the story. Tests like ANA, ESR, CRP, RPR, zinc, 25 hydroxyvitamin D, AST, ALT, creatinine may be important to consider in select patients.

If a trigger can't be found, one always needs to go back to step 1 and ask if this is really telogen effluvium or not. This might be the time that a practitioner is willing to accept that the diagnosis might actually be something else.

If the trigger can’t be found, it might be important to consider a scalp biopsy. Now, let me say from the outset that biopsies are not needed for most patients. A good history and good examine and good blood tests provide the diagnosis and trigger in 95 % or more of patients. But one needs to consider a biopsy in cases that just don’t seem to make sense. Why is the patient shedding? Am I missing a scarring alopecia? Am I missing an early androgenetic alopecia?

Referral to a hair loss specialist is helpful if shedding continues and a trigger just can’t be found.

Will my hair grow back?

Patients with TE often ask me “Will my hair grow back to the density it was before this all started?” Well, despite how common it is for the medical community to reflexively say “Oh, don’t worry it will grow back” that’s just not the correct answer.

The likelihood that hair will regrow fully depends on many factors. First, it depends on whether the trigger was fixed. A patient with TE from low iron who just can’t get the ferritin levels high enough might not get fully regrowth. Of course, they will get some improvement and some reduction in shedding.

A patient with high stress from caring for a dying spouse, might not easily reduce shedding. The stress is still present and hair shedding continues. (Treatments can be tried like minoxidil, laser, PRP, etc but density might not get back 100%. We hope, of course, we come close to 100%).

A patient with a chronic illness with low body weight (BMI 13-16) who just can’t gain weight may not shut off their shedding. The trigger is still present.

In addition, hair sometimes does not grow back to 100% of what it once was in patients with a prior diagnosis of androgenetic alopecia or scarring alopecia. Sometimes it does — especially if the patient is actively treating the androgenetic alopecia and scarring alopecia. Sometimes, the density returns pretty close to 100% (90-100% of original) but the patient senses it’s just not quite the same.

TE Often Resolves When the Trigger is Addressed - But It Can Take Time

With all this behind us, let me way that shedding often resolves when the trigger is properly addressed. it can take 9-12 months for shedding to return to normal but usually it’s closer to 4-7 months. Many patients do get their hair density back to 100% but it takes times for the patient to be convinced that the density truly is back to 100%. It only take 4-7 months usually to be convinced that the shedding has slowed and stopped but it takes a lot longer to see the density come back. Hair only grows 1 cm per month so it takes 1-2 years to grow shoulder length hair again.

A Helpful Algorithm

Below is a helpful algorithm to consider for anyone asking : Will I get my hair back?