The Top 10 Causes of Telogen Effluvium.

Of the many cases of telogen effluvium - five are most common

Telogen effluvium (TE) is a hair shedding disorder whereby the patient experiences more daily hair loss than they may have in the past. Mild effluviums may lead to 50-100 hairs loss daily whereas more severe effluvium may be associated with several hundred hairs lost daily. Many forms of TE occur 2-3 months after a triggering event. A trigger in January, for example, causes hair loss in March. A trigger that occurs in March causes hair shedding in May.

Common Triggers of TE: The Top 5.

There are five common triggers of telogen effluvium. These include

1. Low iron (ferritin levels)

2. Stress

3. Thyroid abnormalities,

4. Starting or Stopping a new medication

5. Weight loss/dieting

Hundreds of other examples of triggers exist as well.  Fortunately, the top 5 are the most common which makes tracking down the potential cause a bit easier. However, when TE does not improve sometimes one needs to consider the less common causes as well as the so called ‘mimickers‘ of TE.

Less Common Causes of TE: Reasons 6 to 10

There are many other less common causes of shedding. One must consider a much larger number of potential causes if patients find their shedding its not improving.

The less common causes of TE include:

1. Internal illness - inflammatory bowel disease, rheumatologic diseases, lupus, other autoimmune diseases, kidney disease, liver disease, internal cancers

2. Vitamin and mineral deficiencies or excesses - zinc levels, B12, vitamin D

3. Infections - syphilis, staphylococcus, viral infections, Lyme disease,

4. Scalp Diseases - seborrheicdDermatitis, psoriasis, and other autoimmune scalp diseases

5. Endocrine Issues - hormone abnormalities of the hypothalamus, ovaries, adrenals, pituitary

The Mimickers of TE

Of course, not all patients who are thought to have telogen effluvium really have telogen effluvium. Several conditions can mimic or closely resemble telogen effluvium and these include:

1. Scarring Alopecia (especially lichen planopilaris)

There are about 10 different types of common scarring alopecias rather than just one type. They all have slightly different epidemiology and clinical features. All of the scarring alopecias are associated with the presence of variable amounts of ‘scar tissue’ in the scalp which blocks hairs from growing properly. Other features include variable amounts of inflammation and reduction in the density of oil glands in the scalp. A pathologist will be able to determine if these histopathological features are present in a scalp biopsy. Many scarring alopecias give symptoms like itching, burning and tenderness, but certainly this is not a mandatory criteria as some patients report little in the way of symptoms. The proper diagnosis of scarring alopecia is essential as the hair loss that occurs in scarring alopecia is permanent and the sooner treatment can be initiated the sooner we can try to stop the disease from progressing further. While we do not always have an ability to regrow back new hair in scarring alopecias, we can often stop the disease from getting worse in up to 70 % of patients. 

Lichen planopilaris is a scarring alopecia that is believed to have autoimmune etiology. The precise cause is unknown in the present day.  The disease is associated with inflammation around hair follicles which triggers the formation of scar tissue in the scalp. This scar tissue is permanent and blocks further growth of hair follicles. There are about 2 dozen treatments for LPP ranging from fairly safe (topical steroids) to milder immunomodulators (doxycycline, hydroxychloroquine) to much more potent immunosuppressives (cyclosporine, azathioprine). Generally speaking, treatment begins with the safest medications in hopes that these safer groups of drugs can stop the disease. If not, one then moves on to consider more potent medications. The duration of time that a patient will be on these medications varies greatly. It ranges from 9 months to several decades. For a small percent of individuals, continued use of medications lifelong is needed to stop the disease. For many people, though, medications are continued several years before they can be tapered and sometimes stopped. In some patients, the disease eventually stops on its own and does not return. We generally help stop the immune system attack on the hair follicles until the time in which the immune system stops on its own.  It is not possible to predict accurately at present how long treatment will be needed for any patient at the first meeting. Over time, it will be possible to predict with slightly greater accuracy as to how the scarring alopecia will progress and how it will respond to these medications.  Hair transplants may be possible for scarring alopecia but only when they have been completely dormant (off all medications) for 2 years.

2. Androgenetic alopecia

Androgenetic alopecia affects approximately 40-50 % of women by age 50 and 60 % of men.. The precise cause remains to be fully worked out but many patients have a genetic history of male balding in parents, or grandparents. Some patients with this type of hair loss do not have strong family histories. Hormones may also play a role in this condition although 85 % have normal hormone levels.  Androgenetic alopecia causes hair follicles to become thinner (miniaturized). At first, only a proportion undergo this change which leads to a significant variation in size of follicles in affected areas of the scalp. Diagnosis of androgenetic alopecia is mainly clinical, meaning that a careful examination of the scalp confirming that there is hair loss in specific areas of the scalp and that the main reason for the reduction in density is hair follicle miniaturizationusually suffices. A biopsy, if performed, will confirm the miniaturization and typically shows a terminal to vellus hair ratio of less than 4:1 provided horizontal sections were used. Treatments, discussed below, are generally life long.

3. Chronic Telogen effluvium

Most telogen effluviums resolve about 9-12 months after the trigger has been completely corrected. The exception is so called chronic telogen effluvium (or CTE). Chronic telogen effluvium (CTE) is a form of shedding occurs in the absence of any identifiable trigger. It occurs mainly in women 35-70 years of age. 

Many patients with telogen effluvium, including CTE,  have scalp symptoms of itching, burning, tenderness, and feeling of something moving in the scalp. This is referred to as trichodynia.

4. Alopecia areata incognito

Alopecia areata incognito (AAI) looks very much like a telogen effluvium and patients have a positive pull test and usally have scalp symptoms (trichodynia). Unlike classic alopecia areata, exclamation mark hairs are not found. However dystrophic and broken hairs are found. The best way to detect these broken and dystrophic hairs is with a modified hair wash test. The patches in AAI are quite small. Eyebrow and body hair loss is not common in AAI. 

Conclusion and Summary.

There are many reasons for telogen effluvium. Top most common causes include stress, low ferritin levels, thyroid problems, medications and weight loss. These ‘top 5’ reasons are important for any hair specialist to commit to memory as they serve as the starting point for further investigations into the cause of shedding. Dozens and dozens of other causes are possible. A careful history, together with a through scalp examination and review of blood tests (the so called Diagnostic S.E.T.) will be essential to determine if any of the top 5 causes of TE are likely implicated and what other testing should be done.