Telogen Effluvium: When Hair Shedding Is A Cause For Concern

Thick and luscious locks are often synonymous to youth and beauty, so it can be worrying when you start losing them by the handful.

Considered as the second most common form of hair loss, telogen effluvium is a reactive non-scarring alopecia characterised by acute hair shedding. The temporary hair loss is caused by excessive shedding of resting hair after experiencing some shock to the system. This hair condition affects people across the board, regardless of one’s age, gender or racial background.

The Pathophysiology Of Telogen Effluvium

For a start, existing follicles undergo hair cycles that consist of 4 main phases: growth (anagen), regression (catagen), rest (telogen) and shedding (exogen). Typically, most scalp hair follicles will grow a hair shaft for an average of 5-6 years, before they transit into the later phases. They would then rest for another 3-6 months, preparing their cells so that when they do receive the impetus to start the next hair cycle, they are able to grow a new hair shaft immediately.

Seeing as how telogen effluvium is a reactive process, a follicle’s anagen phase needs to be interrupted by an injury (either physical or mental). Such an injury has to be big enough that it’ll disrupt the keratinocytes (cells that produce the protein that makes up your hair, skin and nails) mitoses in the hair matrix. This stress will then trigger and push these hairs into the resting phase prematurely, and effectively cease their growth for a few months. When they are ready to finally re-enter the growth phase, they will be extruded from the follicle and fall off.

It is worth noting that diagnosing telogen effluvium from other types of hair loss conditions can be rather tricky. There are several factors that can lead up to hair loss and hair shedding, but a stark identifying marker of telogen effluvium is the phase in which the injury finds the hair follicle.

Should the injury be inflicted during the end of the anagen phase (anagen VI), its mitoses will be mitigated and the result will be a simple quickening of the transition to the telogen phase. The injured hair will then seek refuge during this resting period for another 3 months before it sheds.

How Much Is Too Much?

Naturally, figuring out the exact phase your hair follicles are in is downright impossible. Moreover, the hair cycle in adults is individual, in that each hair follicle follows a cycle that’s independent from the rest.

As such, you would want to take note of the amount of hair you’re shedding on the daily. Losing about 50 to 100 hairs in a single day is considered to be normal, but since telogen effluvium precipitates a greater percentage of your growing hairs to enter the resting phase prematurely, those with this condition will lose more than the typical daily amount. This is usually more than 100 strands/day and patients will report that the hair is falling out in clumps and bunches.

Classifying Telogen Effluvium

Telogen effluvium can be classified into two groups: acute and chronic, according to the duration of disease. Acute telogen effluvium occurs shorter than 6 months, while the chronic state takes more than 6 months.

Telogen effluvium is classified into 5 different pathogenetic mechanisms, namely immediate anagen release, delayed anagen release, shortened anagen, immediate telogen release and delayed telogen release.

Immediate anagen release: This is the most common form of TE which is related to physiological stress including febrile illness. Follicles which are induced to leave the anagen, enter telogen early.

Delayed anagen release: Also known as telogen gravidarum, it typically occurs in women with postpartum hair loss, caused by high levels of circulating placental estrogen which prolongs the anagen phase and leads to great hair growth during pregnancy. Withdrawal of these hormones at delivery however causes the overdue anagen hair to all enter catagen at the same time, leading to increased shedding a few months downstream.

Shortened anagen: Common in hereditary hypotrichosis and ectodermal dysplasia, where the idiopathic shortening of anagen duration results in persistent telogen shedding.

Immediate telogen release: Hair follicles re-enter anagen prematurely, due to drug-induced shortening of normal telogen cycle. This is seen after starting therapy with topical minoxidil as the anagen phase is being concurrently stimulated with the commencement of minoxidil, which leads to the simultaneous release of resting exogen hairs in a shorter timeframe.

Delayed telogen release: Hair follicles remain in prolonged telogen instead of being shed into anagen. There is an increase in shedding of club hair when teloptosis (termination of the telogen phase with hair shedding) sets in. This process likely underlies seasonal shedding of hair in human when travelling from low-daylight to high-daylight environments.

Evaluation For Patients With Telogen Effluvium

For individuals with telogen effluvium, they should be evaluated with a physical examination, a detailed history and tests. This includes identifying possible triggering factors and examining the level of thinning and shedding as well as any associated symptoms like itching and pain.

The physical examination can include:

Hair pull test: About 50–60 hair fibers are grasped and tugged to detect active hair shedding, performed in 4 regions of the scalp: the frontal, occipital, and both temporal regions.

Wash test: Shampooing is skipped for 5 days before the hairs are washed in a basin. Any hair shed is collected in a gauze and classified according to length for diagnosis of acute or chronic telogen effluvium.

Trichogram (hair pluck test): Involves a microscopic examination of hairs plucked from the scalp to measure hair follicle activity and provide information on the state of the proximal end of the hair shaft and the distal end.

Treatment

Similar to its prevention, the treatment for telogen effluvium depends on what is the trigger behind the hair shedding, which includes childbirth, a stressful or major life event, severe trauma or illness, new medication or weight loss and extreme dieting. Once these triggers have been identified and addressed, only then will the hair cycle return back to normal, kickstarting the regrowth of new hairs.

For one, you can take the first step to make sure that your internal bodily state is taken care of – that means having a well-balanced diet that offers all the nutrients you need. You may also want to consume plenty of protein-rich foods such as the amino acid lysine which helps to set the foundation for hair growth.

In cases where hair growth has not returned to satisfactory levels, you may want to see a dermatologist specialising in hair disorders. Upon giving a proper assessment, they’d be able to find a treatment that suits you best and help you restore your locks to its former glory.

Key Takeaways

Losing a substantial amount of hair strands at one time can cause a devastating blow to one’s self-esteem and mental psyche. While telogen effluvium hair loss isn’t usually permanent, it’s good to consult your doctor if your symptoms worsen to help determine what’s behind your hair loss and develop an appropriate treatment plan for you.

At Angeline Yong Dermatology, we employ only the most medically-advanced and rigorously-tested techniques to meet all our clients’ needs and wants all whilst delivering the optimal results. For all your hair troubles, we also offer low-level laser therapy, FUT and FUE hair transplant surgeries aside from oral medications.

As an accomplished skin dermatologist accredited by the Ministry of Health, Dr Angeline Yong was also the founding consultant and lead of the National Skin Centre’s hair transplant service. Her subspecialty interests include hair disorders and hair transplantation. Armed with over 15 years of medical experience, she brings her expertise and knowledge to champion healthy skin and hair for everyone.

If you find that you are suffering from telogen effluvium, or any form of hair issue, don’t hesitate to give our dermatology clinic a call!

References:
1. Rebora A. (2019, February 7). Telogen effluvium: a comprehensive review. Clin Cosmet Investig Dermatol. https://doi.org/10.2147/CCID.S200471
2. Hughes, E. C. (2020, June 9). Telogen Effluvium – StatPearls – NCBI Bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK430848/
3. Harvard Health Publishing. (2019). Telogen Effluvium. Harvard Health. https://www.health.harvard.edu/a_to_z/telogen-effluvium-a-to-z
4. Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The Role of Vitamins and Minerals in Hair Loss: A Review. Dermatol Ther (Heidelb). 2019;9(1):51-70. doi:10.1007/s13555-018-0278-6

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Telogen Effluvium: When Hair Shedding Is A Cause For Concern