Telogen Effluvium

Telogen effluvium (TE) is a common non-scarring diffuse hair shedding caused by premature entry of anagen follicles into the telogen phase after a physiological or pharmacological stress.

• Shedding begins 2 to 3 months after the trigger and usually lasts up to 6 months.
• Triggers: high fever or severe illness, major surgery, childbirth (postpartum), crash dieting and protein deficiency, iron deficiency, zinc deficiency, thyroid disease, stress, COVID-19, and drugs (retinoids, anticoagulants, beta blockers, anticonvulsants, ACE inhibitors, antithyroid drugs, interferon, oral contraceptive withdrawal).
• Chronic TE lasts over 6 months, mostly in women aged 30 to 60.

• Diffuse shedding of 100 to 300 hairs per day (normal under 100), noted in the shower, comb, or pillow, with preserved density in most and bitemporal thinning.
• No scalp symptoms or scarring; the scalp appears normal.
• Positive pull test (more than 10% of hairs, typically club hairs with white bulbs).
• Nails: Beau lines may appear.

• History: timeline of stressors, diet, medications, menstrual history.
• Pull test, hair count, and trichoscopy (short regrowing hairs, no miniaturisation).
• Blood tests: full blood count, ferritin (target above 40 to 70 ng/mL), TSH, vitamin D, B12, folate, zinc, and sometimes iron studies, ANA, and syphilis serology.
• Biopsy if unclear: increased telogen hairs (over 20%) with normal follicle counts.
• Exclude androgenetic alopecia, alopecia areata (diffuse), anagen effluvium, lupus, and secondary syphilis.

• Identify and treat or remove the trigger, as most acute cases recover fully in 6 to 12 months without therapy.
• Correct deficiencies: ferrous sulfate 200 mg once or twice daily for iron deficiency (ferritin below 30 to 40 ng/mL), zinc 25 to 50 mg daily, vitamin D, and adequate protein intake (at least 1 g/kg/day).
• Treat thyroid disease and review implicated medications.
• Minoxidil 5% topical once or twice daily (supports regrowth), gentle hair care, and avoidance of tight hairstyles.
• Chronic TE: investigate for coexisting AGA; consider low dose oral minoxidil 0.5 to 1 mg daily or biotin only if deficient.
• Provide reassurance and a follow up plan with hair counts at 3 to 6 months.