Constant hair shedding for 2 years: Is the diagnosis TE or something else?

2 years of constant hair shedding: Is this just a TE?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of the topic of chronic hair shedding. Hair shedding is often felt by some to be synonymous with telogen effluvium. This is incorrect.

Here is the question….

QUESTON

Hello. Would I be able to ask you a question about TE? I first experienced this in July 2018 4 months after I had my son by c section. Since July 2018 my hair fall has continued at a consistent rate of 70-80 hairs a day. Mostly all falling out in the shower. I’ve had all my blood work done by my doctor and he did a hair pull test and just says it’s TE. What do I do now that it’s almost been 2 years of constant fall out? Mind you the hairs are growing back in, tapered at the ends, sticking straight up, ALL over my entire scalp. The excessive hair fall is not stopping, which makes my hair look extremely thin even though they’re growing back in when one falls out.  
Any advice would be appreciated. My doctor wants me to try rogaine 2% and I don’t know if that’s the solution or not. 

Thank you in advance... 

ANSWER

Thanks for the question and probably one of the most common scenarios I encounter with female hair loss. There’s a lot to discuss with your question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. I’d like to know what blood tests were done in your case and what the results were. I’d like to know if there is any itching, burning or pain in the scalp. I’d like to know if your menstrual cycles are now regular. I’d like to know if the person asking the question has any medical issues or takes any medications. I’d like to know about stress levels? I’d like to know her family history of hair loss. I’d like to know if the patient has lost any brows or lashes. I’d like to know if her weight has been stable? I’d like to know if the density is the same as 6 months ago or worse? I’d like to know if the patient has any headaches, joint pains, skin rashes, dry eyes, dry mouth, thirst, abdominal pain, fatigue, changes in libido, or ulcers the mouth. I’d like to know the precise age of thee patient. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again.

You might have telogen effluvium. But the main point here and the entire reason I chose this as the question of the week, is you might not have TE as the diagnosis or a TE might not be the main reason. I feel strongly that you need another examination or a scalp biopsy.

First, let’s take a look at the reasons why your shedding is not stopping. There are several reasons why shedding does not stop in women. I don’t know anything about your story and don’t have photos of your scalp so I can’t say which of these 3 reasons (see below) it is. However, I’d encourage you to meet with an expert dermatologist as he or she might assist you in determining which of the following is applicable to you.

REASON 1: You have telogen effluvium, but you have not found the trigger

I’d possible you have telogen effluvium as the “only” diagnosis, but I doubt it. If, in fact, you do have isolated TE, then you may still be shedding because you have not found the trigger of the shedding. Causes of telogen effluvium include stress, low iron, thyroid problems, medications, crash diets, weight loss, illness inside the body. Which one is relevant to you?

I’m hoping you have had blood tests done already … but if not, you need them. A person with shedding of hair needs CBC, TSH, ferritin, vitamin D at minimum. In someone with your story, other tests like ANA, zinc, testosterone, DHEAS, ESR, VDRL may be important to consider. There could be other tests you need too! The exact tests that you need depend on your entire story. There are about 50 tests possible but most people need 5-10. It would only be possible for me to list the blood tests you need if I knew about your entire story from A to Z

it’s possible you are still shedding because there still is a trigger telling your hair to shed. If so, you are your doctor need to find it. Is there something in the blood test results? Do you need more blood tests? is there a medication causing your shedding - like birth control? like a prescription mediation? Do you have any medical issues that you do or don’t know about that are causing the shedding? Is your diet adequate to sustain hair growth?

REASON 2 You have telogen effluvium but also have another diagnosis or you don’t really have TE at all

You might have telogen effluvium but there may be a second diagnosis present that you are your doctor are not recognizing - or you might not really have TE at all. The most common scenario is a patient who has TE but also has evolving androgenetic alopecia (AGA). It’s not uncommon for AGA to start in some when after delivery of a baby and then progressively get worse. When the condition first starts up the only thing that is experienced by the patient is shedding. For many women with AGA, this shedding is all over the scalp so this fact alone does not just mean you could only have TE.

So, it could be that you have TE + AGA or it could be that you don’t really have TE but rather you have only AGA that is mimicking TE. If you feel there is less hair on your hair today compared to one year ago, then there is a reasonable high chance you have AGA as one of your diagnoses or the only diagnosis. If there is the SAME amount of hair on your scalp compared to 1 year ago, then it’s still possible that TE is the only diagnosis that you have.

Be sure to see a dermatologist who specializes in hair loss for the proper diagnosis. A skilled dermatologist might be able to determine if you have androgenetic alopecia (also known as female pattern hair loss) simply by looking at the scalp with dermosopy. If not, then a scalp biopsy can be done. If you want to get some clues yourself, then you might consider performing a test yourself known as the five day modified hair wash test.

You can read more about this in the link above, but it essentially involves collecting every single hair that exits your scalp exactly five days after not shampooing your hair. If you see mostly long hair, it’s like TE. As a person starts to see an increasing number of short hairs, the possibility of androgenetic alopecia goes up. Now, I always suggest that the 5 day wash test be explained to your properly by your dermatologist and then interpreted properly by your dermatologist. But it is an option to get further clues about what diagnosis might be going on .

We also need to keep in mind that there are many other conditions besides just AGA and TE that cause shedding. Scarring alopecias are one of them. Lichen planopialris for example can cause constant shedding. It woudl be unusual for a person with your story to have scarring alopecia but not impossible. If there is burning on the scalp or tender sore areas on the scalp or redness in the scalp, the chances that a person has scarring alopecia goes up a bit. Alopecia areata incognito (a form of alopecia aerate) is another cause of shedding that mimics TE. A consultation with an experienced dermatologist can help determine if you have any other mimickers of telogen effluvium.

REASON 3: You have chronic idiopathic telogen effluvium or what is termed “CTE”

A person with chronic shedding may have CTE. Your story is certainly not typical of CTE but you’ll probably hear that term thrown around a lot. Most women with classic CTE have thick hair that sheds and sheds and sheds. Thinning is not obvious. You are in the wrong age group for CTE. You have what sounds like progressive thinning. While you could ‘potentially’ have a TE that follows what we talked about under reason 1, you probably don't have CTE. Again, a dermatologist can assist you.

SUMMARY

In summary, you might want to see an expert dermatologist in your city for diagnosis. I’m suspicious that TE is the only diagnosis you have. It might not be. You need to make sure you’ve had a proper examination and determine if other issues like AGA, alopecia areata or scarring alopecia are at all present on your scalp. The most likely of all of these is AGA. You need to make sure that you’ve had all the blood tests ordered based on your story. There may be 5 tests you need or 25 tests -it depends on your story that you share with your doctor. If anyone is still not sure about the diagnosis or you yourself are not confident with the diagnosis being told to you, a modified hair wash test could be a first step, or a scalp biopsy. A biopsy woudl be preferred in your case. A properly done scalp biopsy with horizontal sections and determination of the so called terminal to vellus ratio (T:V ratio) is going to go a long way to helping. IF your T:V is above 4 with lots of telogen hairs in the biopsy (above 15%), then isolated TE may be what you do have. If your T:V ratio in the biopsy is less than 4:1 then you probably have AGA. The biopsy can also help determine if you do have scarring alopecia or do have alopecia areata.

I hope this helps.

Good luck,