Telogen effluvium is a reactive process, triggered by metabolic stress, hormonal changes, or medications. Common triggering events are acute febrile illness; severe infection; major surgery; severe trauma; postpartum hormonal changes, particularly a decrease in estrogen; hypothyroidism; discontinuing estrogen-containing medication; crash dieting; low protein intake; heavy metal ingestion; and iron deficiency. Many medications have been linked to telogen effluvium, but the most common are beta-blockers, retinoids (including excess vitamin A), anticoagulants, propylthiouracil, carbamazepine, and immunizations.
Telogen effluvium can occur in people of any age, any gender, and any racial background. The exact prevalence of telogen effluvium is not known, but it is considered to be quite common. A large percentage of adults experience an episode of telogen effluvium at some point. Telogen effluvium can occur in either sex, though women have a greater tendency to experience this condition because of postpartum hormonal changes. Also, women are more disturbed by hair shedding than men and are therefore more likely to seek medical attention. 
Telogen effluvium is triggered when a physiologic stress causes a large number of hairs in the growing phase of the hair cycle (anagen) to abruptly enter the resting phase (telogen). The growth of the telogen hairs ceases for 1 to 6 months (on average 3 months), though this cessation of growth is not noticed by the patient. When the hairs reenter the growth phase (anagen), the hairs which had been suspended in the resting phase (telogen) are extruded from the follicle, and hair shedding is observed.
Histologic findings in telogen effluvium are best seen in transverse sections of a punch biopsy.
Patients will report hair shedding, usually without other symptoms, with a relatively abrupt onset. By definition, in acute telogen effluvium, shedding lasts less than six months; often the period of shedding is much shorter. A careful history will identify a causative event (see etiology section) occurring approximately 3 months before the onset of the shedding (range from 1 to 6 months). Quite often the patient has fully recovered from the acute illness and fails to see the connection between the illness with the hair loss.
The physical examination is grossly normal, as it is difficult for the casual observer to appreciate the loss of hair volume. It can be helpful to compare the patient's current appearance with old pictures. If the patient presents during the acute shedding, a gentle pull test yields at least four hairs removed with each pull. However, if the patient presents after the acute shedding has passed, the pull test may be normal. Careful examination of the scalp will show an increased percentage of short anagen hairs growing close to the scalp.
Usually, a careful history and physical examination are sufficient to diagnose telogen effluvium. Biopsy, if taken during the acute shedding phase (when the pull test is positive), can confirm an increase in the percentage of telogen hairs. If there is a concern for a hormonal condition (such as hypothyroidism), a chronic metabolic illness, or iron deficiency, testing for these conditions is indicated.
Chronic telogen effluvium sometimes has a metabolic cause.
Acute telogen effluvium is a self-limited condition. If the causative event is identified by history and has been adequately treated, there is no further treatment required. If a hormonal or dietary imbalance or metabolic illness is present, hair growth will return after these factors are corrected. If a medication is the cause of the shedding, hair growth will restart after the medication is withdrawn.
Hair transplantation has no role in the treatment of telogen effluvium.
While topical minoxidil has not been proven to promote recovery of hair in telogen effluvium, it has theoretical benefit. Patients who wish to take an active role in their treatment may choose to use minoxidil.
The differential diagnoses includes:
Morbidity is generally limited to mild cosmetic changes which are mild. Mortality has not been reported.
It may take up to 6 months for hair growth to restart, and even longer for the growth to be appreciable by the patient. Patients often require reassurance of the normal recovery of their hair while the hair reenters anagen and grows normally. Patients may also worry that normal grooming of their hair worsens the hair shedding. Patients should be reassured that their hair is normal and that they can wash and style their hair as usual.
The diagnosis and management of hair loss is with an interprofessional team that includes a dermatologist, primary care provider, nurse practitioner, and an internist. One type of hair loss is Telogen effluvium, which is a form of nonscarring alopecia characterized by diffuse, often acute hair shedding. In most cases, no cause is ever found. In any case, patients need to be educated that the condition is self-limiting. There is no need to prescribe hair growth medications or refer the patient for a hair transplant. The hair growth will return but it may take a few months or even a year. For most patients, the outcome is good. (Level V)
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