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

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Alopecia areata (a hair losing disease): The ultimate guide for patients

 One fine evening you just took a shower and you were getting ready for a party…while styling your hair you suddenly felt something odd…you just asked your mom to look and oh my goodness me…what is this…a round patch of baldness suddenly came from nowhere. That just might be alopecia areata.

Or

You are having hair fall issues for few weeks. Suddenly people start asking you why your hair is becoming greyer day by day. Are you suddenly becoming old? Certainly not. That might be alopecia areata as well.

Or

You just have had a clean shave few days back for a date. After few days when the beard starts to grow, you suddenly realize there is a round area where the beard is not coming back. And you might be thinking who ate that. Sorry, no one. It’s also a type of alopecia areata.

Though it’s not as common as pimples but alopecia areata has a global prevalence of around 2% ^{(https://pubmed.ncbi.nlm.nih.gov/31437543)}

I used to work in a govt. hospital OPD, where around 200-300 patients used to come daily. Among them I found at least 2-3 patients with alopecia areata daily. Most of them are aged between 10-40.

What is alopecia areata?

It is a hair losing disease, causing rapid and complete loss of hair from one or more round or oval patches, most commonly from scalp, bearded areas, eyebrows and less commonly from other hairy parts of the body.

How can you diagnose alopecia areata as a patient?

1.    Sudden appearance of a round or oval patchy hair loss of 1-5 cm in diameter over scalp or bearded area or eyebrows or any other hairy part of body.

2.    There may be single or multiple patches. Patches may join to form large area of hair loss. Complete loss of scalp hair can occur (alopecia totalis). Complete loss of all body hair may also occur (alopecia uliversalis).

3.    Spontaneous regrowth can occur over a patch. Newly growing hairs are typically grey or white which can regain pigmentation later on.

4.    White hairs are rarely affected. So if you have white and black hair evenly distributed over your scalp then you may notice that hairs are becoming greyer or whiter within days. It can occur in case of diffuse alopecia areata which is difficult to diagnose.

5.    There may be some changes in your nail in severe cases like pitted nail (small depressions on nail surface), rough nail etc.

Why does alopecia areata occur?

See, our immune system is built to protect us from foreign particles like bacteria or virus. But when our own immune system works against our own body then it causes autoimmune disease (over simplified). Alopecia areata is a type of autoimmune disease. Here T-Lymphocytes (a cell of our body which is a part of our immune system) gets activated and attacks hair producing cells. That causes hair loss. But it does not destroy the hair follicle fully. And that is why hair loss in this disease can be reversible.

Genetic factors also have some role. About 25% patients have positive family history.

What are the other important things to keep in mind?

1.    Other autoimmune diseases like thyroiditis, lupus erythematosus, psoriasis or vitiligo may be associated with it.

2.    Patients with atopic dermatitis (a type of eczema in short) may present more severe disease and at an earlier age.

3.    So if you have other health issues or problems, you must share everything in details with your doctor.

Why should you visit a qualified dermatologist ASAP?

See, my intention to create this post is to enlighten and to educate the patient, not to diagnose the disease and start self-medication. This is not a kind of disease where you can treat yourself at home without consulting a doctor.

In children, a similar looking alternate possibility is tinea capitis (a fungal infection of scalp). Androgenetic alopecia, early lupus erythematosus, syphilis are some other possibilities. You can’t differentiate between these diseases by your own. Neither you can treat any of these diseases by yourself.

As there may be spontaneous regrowth of hair in some cases, you might be reluctant to go to a doctor. You may think that the problem will get cured by its own. But during that phase of regrowth suddenly a new patch of hair loss may appear within days.

If the re-growing hair remains grey or white for long duration, there is a possibility of associated vitiligo. So you must visit a qualified dermatologist as soon as you detect the problem.

Prognosis

In my practice I have seen more than 50% patients had complete recovery within 6-12 months. Even in a patient with alopecia totalis, compete hair regrowth was achieved by proper treatment within 8 months. But unfortunately most of the patients come with similar episodes in the future.

Association with atopic dermatitis, early age on disease onset and more extensive involvements are some bad prognostic factors.

What can you do?

1.    Try to recognize the problem as soon as possible.

2.    Maintain proper diet rich in vitamins, minerals and antioxidants.

3.    Avoid foods with high sugar content.

4.    Seek help of a specialist ASAP.

What should you not do?

1.    Don’t panic and don’t get over stressed.

2.    Don’t delay in seeking help from a qualified dermatologist.

3.    Do not self-medicate yourself or apply anything on your scalp without consulting your dermatologist.

Treatment

Multiple treatment modalities are available. Let your dermatologist chose the best treatment for you.

Source

1.    https://pubmed.ncbi.nlm.nih.gov/31437543/

2.    Andrew’s diseases of the skin – clinical dermatology, 12^th edition, chapter 33

3. Rook’s textbook of dermatology, 9^th edition, chapter 89

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