Massive hair loss (Telogen effluvium?): An ultimate guide for patients

 

You are a new mother now. Had your delivery few months earlier, and it is your happiest moments of life. But sudden excessive hair loss may ruin your happiness in some quantity right? Yes, that might be telogen effluvium.

Or

You went in to crash dieting to lose weight quickly. After few months, you woke up in the morning and Oh no! You just found a hefty amount of fallen hair on your pillow. Yes, that might also be telogen effluvium.

Or

You had a major surgery 2 months back and now you are suffering from sudden diffuse hair loss. It is certainly telogen effluvium.

  

What is Telogen?

 Human hair growth is cyclical. Each individual hair follicle goes through cyclical changes. One of that phase is called telogen.

What is telogen effluvium?

In simple terms, it is sudden excessive loss of hair which starts after 2-3 months following a stressful life event (like childbirth, a surgery, crash dieting, major illness or drug induced).

What do I mean by “excessive hair loss”?

Let us do a simple math. We have 100000 hairs in our scalp. Among them 10% which is 10000 are telogen hairs. All these 10000 hairs, which are of different ages, will fall at an age of 90 days. So normal hair loss per day will be 10000/90 = around 111.

The actual figure is around 100-150. So, more than 150 hair loss per day can be termed as excessive.

Do we really need to count this to measure excessive hair loss?

No.

So how do we measure “excessive hair loss”?

Pull test – Grasping about 40 hairs firmly between thumb and forefinger, followed by a slow pull which causes minimal discomfort. Shedding of more than 4-6 hairs in patients who has not shampooed their hair for more than 24 hours prior to the test (more than 2-3 in recently shampooed hair) is abnormal.

A technique developed by Dr. Jeffrey Miller – Patient combs hair from vertex to anterior hairline for 1 minute before shampooing on 3 consecutive days. Normal range of lost hair by this technique is 10-15. Loss of more than 50 is common in telogen effluvium.

 

Types and causes of telogen effluvium

1. Acute telogen effluvium – Sudden onset of scalp hair loss that occurs 2-3 months after a triggering factor. Regrowth can be expected within 3-6 moths. Causes –
   
   
   
   
   
2. Chronic diffuse telogen hair loss – Hair shedding persisting for longer than 6 months. Causes –
   

   
   
   
   
3.  Primary chronic telogen effluvium – It mainly affects women aged between 30 and 50 years. Appears as a sudden onset of increased hair loss which lasts for more than 6 months. The course is prolonged and fluctuating. Usually no triggering factor is found.

Why does this massive hair loss occur?

Digging deep into the pathogenesis won’t help my audience. But understanding the pathophysiology is an important part of patient counselling which reduces apprehension and anxiety of a patient. So, I will try to be as simple as possible.

The triggering factor causes disruption in the normal hair growth cycle. All of a sudden a lot of anagen hairs (which lives for years) are converted to telogen hairs (which lives for around 3 months). So after 3 months the extra telogen hairs starts falling off along with the 100-150 hairs that normally shed per day. This causes excessive hair loss.

Telogen effluvium at Childbirth (telogen gravidarum) is a bit different scenario. Here during pregnancy follicles may remain in prolonged anagen. At delivery many follicles are then released simultaneously in to telogen and shedding occurs after 3-5 months.

Do you need to run to a dermatologist?

Yes, and No. Confused?

Ok. Let me clear your doubts.

To give a perfect answer to this obvious question, first let me discuss prognosis, investigations and treatment options.

·      Prognosis –

v Acute telogen effluvium (ATE) – When the triggering factor gets resolved or eliminated a complete regrowth can be expected within few months. Ha

v Chronic diffuse telogen hair loss (CDTHL) – When the triggering factor gets identified and treated accordingly complete hair regrowth is expected. So here also the prognosis is good.

v Primary chronic telogen effluvium (PCTE) – Here no triggering factor is identified. Even after prolonged and fluctuating course of hair loss for no major reduction in hair density is observed. This also suggests a good prognosis.

·      Investigations required –

v ATE – No investigations required as spontaneous growth occurs after few months.

v CDTHL and PCTE – Distinction between these two required meticulous physical examination and laboratory studies to rule out causative factors.

·      Treatment –

v ATE-

1.    Observation

2.    Reassurance

3.    Counselling

v CDTHL-

1.    Treatment of the triggering diseases when diagnosed.

2.    Reassurance

3.    Counselling

4.    Few medications have been tried with no permanent or universal solution.

v PTCE-

1.     Reassurance

2.    Counselling

3.    Few medications have been tried with no permanent or universal solution.

So you see the main part of management is treatment of any triggering diseases if found along with reassurance and counselling.

So what I’ll suggest is, if you have only sudden excessive diffuse hair fall and you can correlate the timing with your childbirth or febrile illness or any surgery or crash diet or any new medications that you have started within last few months, then you just observe it for at least 6 months and then decide.

If you have other physical problems or you are suffering psychologically because of your hair fall, then you should definitely seek advice from a doctor.

If you are having excessive hair loss for more than 6 months, then also you should visit a dermatologist for proper diagnosis and management.

 

Source

1.    https://www.philipkingsley.com/hair-guide/hair-science/hair-growth-cycle

2.    Andrews’ Diseases of the skin –clinical dermatology, 12^th edition, chapter 33, page 749-750

3.    Fitzpatrick’s Dermatology, 9^th edition, chapter 86

4. Rook’s Textbook of Dermatology, 9^th edition, Chapter 89.24-28