Evaluation and Treatment of Sudden Hairloss Telogen Effluvium
A careful history of possible triggers is important in patients presenting with TE. Iron and thyroid levels are usually checked and supplements given if deficiency is discovered. In patients with acute TE, discuss the condition as a synchronized shedding. Reassure the patient that there is a 95% chance of complete recovery. It is important to stress that no one goes bald from TE and that every shed hair is replaced.
No specific treatment is required other than reassurance. In the case of identification of a medication as a possible trigger, it is sometimes possible for the patient to continue the medication and still have resolution of her shedding. Alternatively, a medication change, if possible, can be discussed with the patient’s primary care physician. Medications that have been implicated in TE include coumadin, lipid lowering statins isotretinoin, beta blockers, and ACE inhibitors. Discontinuation of exogenous estrogens is often implicated in TE. The patient may want to restart her estrogen therapy, but this is not necessary.
Patients with chronic TE present a more difficult situation. It is difficult to tell a patient that there may be no identifiable cause for her shedding and that there is no specific treatment. As with acute TE patients, check for iron and thyroid deficiency and correct this if identified. Counsel the patient that her increased shedding is due to a shortening of the growth phase of the hair cycle (anagen). It is not known why this occurs. Emphasize that her follicles continue to grow and cycle, however the follicles are simply cycling too fast. Stress that every shed hair is replaced and she will not go bald.
The reason that her hair feels (and is) thinner overall is that she has increased daily shedding and even though each shed hair is replaced, it takes months for a new hair to grow long enough to contribute to the overall hair thickness. Therefore, if double the normal number of hairs is shed daily, the overall hair thickness will be cut in half. Patients with chronic TE require a lot of reassurance. Over time, patients realized that they really haven’t gone bald despite continued increased shedding and this decreases the anxiety they feel about their condition. I have tried treating chronic TE patients with minoxidil because minoxidil has been shown to keep follicles in anagen longer. However, it is usually impractical to use in patients with chronic TE because they have enough hair density to make it difficult to apply the solution to the scalp (the hair becomes matted and greasy) and because minoxidil temporarily increases hair shedding in approximately 10% of users. There have been no studies examining the treatment of chronic TE with minoxidil or any other therapy.