86: Telogen Effluvium

Question 1

What is telogen effluvium and how is it characterized?

Answer 1

Telogen effluvium is the most common cause of diffuse hair loss, characterized by increased telogen club hair shedding. It is subdivided into acute telogen effluvium, chronic diffuse telogen hair loss, and chronic telogen effluvium.

Question 2

What are the common causes of telogen effluvium?

Answer 2

Common causes of telogen effluvium include premature termination of the anagen phase of hair follicles due to factors such as drugs (e.g., heparin), stress, febrile illness, and hormonal changes associated with menstruation and gestation.

Question 3

What demographic is most likely to suffer from acute telogen effluvium?

Answer 3

Elderly women are most likely to suffer from acute telogen effluvium, with a noted female predominance due to stronger awareness of daily hair conditions and dynamic hormonal changes.

Question 4

What is the clinical significance of increased hair shedding in telogen effluvium?

Answer 4

Increased hair shedding can be the only objective sign in telogen effluvium, and loss of more than 25% of scalp hairs is necessary to clinically detect diffuse hair loss, indicating that most cases may be subclinical.

Question 5

What are the different types of telogen effluvium?

Answer 5

Telogen effluvium is subdivided into: 1. Acute telogen effluvium 2. Chronic diffuse telogen hair loss 3. Chronic telogen effluvium

Question 6

How would you differentiate between telogen effluvium and anagen effluvium?

Answer 6

Telogen effluvium involves diffuse shedding of club hairs with no scarring, while anagen effluvium involves rapid hair loss due to damage to the hair matrix, often with broken hairs.

Question 7

What is the mechanism of hair shedding after starting minoxidil?

Answer 7

The mechanism is immediate telogen release due to accelerated exogen. Counsel the patient that this is temporary and regrowth will follow.

Question 8

What are the primary characteristics of telogen effluvium and its subtypes?

Answer 8

Telogen effluvium is characterized by increased telogen club hair shedding and is the most common cause of diffuse hair loss. It is subdivided into: 1. Acute telogen effluvium 2. Chronic diffuse telogen hair loss 3. Chronic telogen effluvium.

Question 9

What is the pathogenesis of immediate anagen release in telogen effluvium?

Answer 9

Immediate anagen release in telogen effluvium involves premature termination of the anagen phase of hair follicles, leading to entry into the telogen phase. Common triggers include drugs (e.g., heparin), stress, and febrile illness.

Question 10

How does the epidemiology of telogen effluvium differ among various demographics?

Answer 10

Loss of more than 25% of scalp hairs is necessary to clinically detect diffuse hair loss, making most cases likely subclinical. Increased hair shedding can be the only objective sign. Low incidence in children. Elderly women are most likely to suffer from acute telogen effluvium.

Question 11

What are the clinical implications of delayed anagen release in telogen effluvium?

Answer 11

Delayed anagen release in telogen effluvium is characterized by a prolonged anagen period that is eventually terminated, resulting in synchronous telogen hair shedding. A common example is the postpartum period.

Question 12

What is the most representative manifestation of telogen effluvium regardless of subtype?

Answer 12

The most representative manifestation of telogen effluvium is diffuse excessive shedding of club hairs without an enclosing sac and pigmentation.

Question 13

What is the typical shedding timeline for acute telogen effluvium?

Answer 13

Shedding in acute telogen effluvium is noted 2 to 4 months from causative events, with regrowth expected by 3 to 6 months.

Question 14

What are the characteristics of shedding in newborns related to telogen effluvium?

Answer 14

In newborns, shedding starts within 4 months after birth, is completed before the first 6 months of life, and involves 60-80% telogen hair.

Question 15

What causes immediate anagen release in febrile illness?

Answer 15

Immediate anagen release in febrile illness is caused by high fever, which can stress hair-producing matrix cells and lead to early anagen release.

Question 16

What is the timeline for delayed anagen release postpartum?

Answer 16

Delayed anagen release postpartum occurs 2 to 3 months after childbirth, with a trichogram showing 94.4% anagen hairs in the second and third trimesters.

Question 17

What is the likely mechanism of hair shedding 3 months after a febrile illness?

Answer 17

The likely mechanism is immediate anagen release due to physiologic stress on hair-producing matrix cells. Shedding starts 3-4 months after the illness.

Question 18

What is the underlying mechanism of hair shedding 2 months after childbirth?

Answer 18

The mechanism is delayed anagen release, where the anagen period is prolonged during pregnancy and terminated postpartum. Regrowth is expected within 3-6 months.

Question 19

What is the likely mechanism of hair shedding after surgery?

Answer 19

The mechanism is immediate anagen release due to surgical stress. Manage with reassurance and observation.

Question 20

What are the characteristics of acute telogen effluvium?

Answer 20

Shedding occurs 2 to 4 months after causative events, characterized by no signs of inflammation or scarring. Regrowth can be expected within 3 to 6 months.

Question 21

How does febrile illness lead to immediate anagen release?

Answer 21

Shedding starts 3 to 4 months after the illness and continues for 3 to 4 weeks. High fever can cause physiological stress to hair-producing matrix cells.

Question 22

What are the implications of surgery on hair shedding patterns?

Answer 22

Surgery can lead to telogen effluvium due to factors such as fever, general anesthesia, and changes in hormones and nutrition levels.

Question 23

What is the significance of delayed anagen release in postpartum alopecia?

Answer 23

Postpartum alopecia occurs 2 to 3 months after childbirth, with a trichogram showing that 94.4% of hairs are in the anagen phase during the second and third trimesters.

Question 24

What is the expected timeline for hair shedding and recovery after initiating medications that cause immediate anagen release?

Answer 24

Shedding starts 2 to 3 months after initiation of medication, and recovery can be expected 3 months after termination.

Question 25

What are some common drugs associated with immediate anagen release?

Answer 25

Common drugs include anticoagulants, anti-infective agents, cardiovascular drugs, psychotropics, oral contraceptive pills (OCPs), and retinoids.

Question 26

What is the relationship between thyroid disease and hair regrowth?

Answer 26

Hair regrowth can be observed around 8 weeks after initiation of thyroid hormone replacement in patients with hypothyroidism.

Question 27

How does aging affect hair loss?

Answer 27

Aging is associated with diffuse hair loss in the scalp and body, along with a histopathologic increase in the telogen ratio.

Question 28

What are the implications of zinc deficiency on hair health?

Answer 28

Zinc deficiency can lead to conditions such as acrodermatitis enteropathica, characterized by hair loss, dermatitis, diarrhea, immunodeficiency, and growth retardation.

Question 29

What dietary factors can contribute to chronic diffuse telogen hair loss?

Answer 29

Chronic diffuse telogen hair loss can be influenced by malnutrition, particularly in protein-deficient elderly subjects and children with protein-calorie malnutrition.

Question 30

What is the significance of serum ferritin levels in relation to hair loss?

Answer 30

Serum ferritin levels below 40 mg/dl indicate iron deficiency, which is controversial in its direct impact on hair loss.

Question 31

What is the likely cause of diffuse hair loss with a history of rapid weight loss?

Answer 31

The likely cause is telogen effluvium due to caloric restriction or malnutrition. Management includes nutritional counseling.

Question 32

What clinical features and management would you expect in a patient with diffuse hair loss and zinc deficiency?

Answer 32

Clinical features include hair loss, dermatitis, and diarrhea. Management involves zinc supplementation.

Question 33

What is the likely diagnosis for hair shedding after a crash diet?

Answer 33

The likely diagnosis is telogen effluvium due to caloric restriction. Management includes restoring adequate nutrition.

Question 34

How would you confirm and manage hair loss in a patient with thyroid dysfunction?

Answer 34

Confirm with thyroid function tests showing hypothyroidism. Manage with thyroid hormone replacement.

Question 35

What are the implications of acquired zinc deficiency on hair loss?

Answer 35

Acquired zinc deficiency can lead to hair loss and is associated with conditions like acrodermatitis enteropathica.

Question 36

What dietary factors can contribute to chronic telogen effluvium in elderly patients?

Answer 36

Protein-calorie malnutrition in elderly subjects can lead to chronic telogen effluvium.

Question 37

What systemic illnesses are associated with telogen effluvium?

Answer 37

Systemic illnesses associated with telogen effluvium include lymphoproliferative disease, advanced malignancy, collagen diseases, hepatic disease, chronic renal failure, systemic amyloidosis, and inflammatory bowel disease.

Question 38

What are the characteristics of chronic telogen effluvium?

Answer 38

Chronic telogen effluvium is characterized by idiopathic diffuse club hair loss in middle-aged women, abrupt onset, prolonged anagen duration, and marked bitemporal recession of hair.

Question 39

What diagnostic criteria should be considered for telogen effluvium?

Answer 39

Diagnostic criteria for telogen effluvium include hair examination, hair loss count, and hair pull test.

Question 40

What are some potential triggers for telogen effluvium?

Answer 40

Potential triggers for telogen effluvium include systemic illness, psychological stress, biotin or fatty acid deficiency, exposure to heavy metals, and sunlight.

Question 41

What diagnostic steps should be taken for a patient with diffuse hair shedding for 7 months?

Answer 41

Perform a hair pull test, trichogram, and trichoscopy. Check for increased telogen hair ratio and conduct laboratory tests for thyroid function, serum ferritin, and zinc levels.

Question 42

What condition should you suspect in a 50-year-old woman with diffuse hair loss and bitemporal recession?

Answer 42

Suspect chronic telogen effluvium. Confirm with a trichogram showing prolonged anagen duration.

Question 43

How does systemic lupus erythematosus (SLE) contribute to telogen effluvium?

Answer 43

SLE contributes to telogen effluvium through systemic inflammation and potential medication side effects.

Question 44

What is the likely mechanism of hair shedding in a patient with chronic renal failure?

Answer 44

The mechanism is systemic illness-induced telogen effluvium. Perform a hair pull test and laboratory tests for renal function.

Question 45

How would you confirm and treat hair loss in a patient with biotin deficiency?

Answer 45

Confirm with laboratory tests showing low biotin levels. Treat with biotin supplementation.

Question 46

What is the likely cause of diffuse hair loss in a patient with a history of UV exposure?

Answer 46

The likely cause is telogen effluvium due to UV-induced damage. Confirm with a trichogram showing increased telogen hairs.

Question 47

What is the mechanism of hair loss in a patient with HIV?

Answer 47

The mechanism is immediate anagen release due to systemic illness. Manage by addressing the underlying HIV infection.

Question 48

What diagnostic tests would you perform for a patient with diffuse hair loss and heavy metal exposure?

Answer 48

Perform laboratory tests for heavy metals like arsenic, thallium, and selenium.

Question 49

What is the likely mechanism of diffuse hair loss in a patient with HIV?

Answer 49

The mechanism is immediate anagen release due to systemic illness. Manage by addressing the underlying HIV infection and providing supportive care.

Question 50

What diagnostic tests should be performed for diffuse hair loss with a history of heavy metal exposure?

Answer 50

Perform laboratory tests for heavy metals like arsenic, thallium, and selenium. Confirm with a trichogram showing increased telogen hairs.

Question 51

What is the likely diagnosis for diffuse hair loss in a patient with eosinophilia-myalgia syndrome?

Answer 51

The likely diagnosis is telogen effluvium due to systemic illness. Confirm with a trichogram and laboratory tests for eosinophilia.

Question 52

What is the likely mechanism for diffuse hair loss in a patient with collagen disease?

Answer 52

The mechanism is systemic inflammation-induced telogen effluvium. Perform a hair pull test, trichogram, and laboratory tests for collagen disease markers.

Question 53

What is the likely cause of diffuse hair loss in a patient with pancreatitis?

Answer 53

The likely cause is telogen effluvium due to systemic illness. Confirm with a trichogram showing increased telogen hairs.

Question 54

What is the likely mechanism of diffuse hair loss in a patient with contact dermatitis?

Answer 54

The mechanism is telogen effluvium due to inflammatory damage. Manage by avoiding the irritant and providing supportive care.

Question 55

What is the likely diagnosis for diffuse hair loss in a patient with systemic amyloidosis?

Answer 55

The likely diagnosis is telogen effluvium due to systemic illness. Confirm with a trichogram and laboratory tests for amyloidosis markers.

Question 56

What are the potential systemic illnesses associated with chronic telogen effluvium?

Answer 56

Chronic telogen effluvium can be associated with systemic illnesses such as: - Lymphoproliferative disease - Advanced malignancy - Collagen diseases (e.g., SLE, DM) - Hepatic disease - Chronic renal failure - Systemic amyloidosis - Eosinophilia-myalgia syndrome - Inflammatory bowel disease (IBD)

Question 57

What psychological factor is controversially linked to immediate anagen release in hair loss?

Answer 57

Psychological stress is controversially linked to immediate anagen release in hair loss, suggesting that stress may trigger hair loss by affecting the hair growth cycle.

Question 58

What distinguishes chronic telogen effluvium from other forms of hair loss?

Answer 58

Chronic telogen effluvium is characterized by: - Idiopathic diffuse club hair loss, primarily in middle-aged women - Abrupt onset and extension beyond 6 months, often with fluctuations - Prolonged anagen duration compared to other forms of hair loss - Marked bitemporal recession of hair - Long-term follow-up showing no visible reduction in hair density even after years of fluctuating hair loss.

Question 59

What diagnostic criteria should be considered when suspecting telogen effluvium?

Answer 59

When suspecting telogen effluvium, the following diagnostic criteria should be considered: 1. Hair appearance: Assessment of global hair thickness and part width. 2. Hair loss count: Daily telogen hair loss varies, with a gold standard of more than 100 being abnormal. 3. Hair pull test: Conducted on a patient who has not shampooed for more than 24 hours, pulling 40 to 60 hairs from three scalp areas (frontal, occipital, temporal).

Question 60

What indicates active shedding in hair loss assessment?

Answer 60

Active shedding is indicated when: - More than 10% of tested hairs are collected, or - More than 5 to 6 hairs are consistently pulled from 2 or more areas.

Question 61

What is the significance of tapered 'pencil point' hairs in hair loss evaluation?

Answer 61

The presence of tapered 'pencil point' hairs suggests alopecia areata.

Question 62

What is the normal telogen-anagen ratio in hair loss assessment?

Answer 62

Normal values for the telogen-anagen ratio are between 4 to 20%, with an average of 13%.

Question 63

What does a telogen rate exceeding 25% indicate?

Answer 63

A telogen rate exceeding 25% suggests acute Telogen Effluvium (TE).

Question 64

What is the purpose of a trichogram in hair loss diagnosis?

Answer 64

A trichogram is used to assess hair root morphology and collect the telogen-anagen ratio, which helps in diagnosing hair loss conditions.

Question 65

What is the difference between phototrichogram and trichoscan?

Answer 65

| Feature | Phototrichogram | Trichoscan | |---------|----------------|-----------| | Method | Comparison of sequential photographs of shaved scalp area | Automated version of phototrichogram using digital software | | Invasiveness | Noninvasive but requires shaving | Noninvasive | | Quantitative Info | Provides little quantitative info regarding hair cycle phase | Useful for evaluation of hair growth in clinical trials |

Question 66

What signs are suggestive of Telogen Effluvium (TE) during trichoscopy?

Answer 66

Signs suggestive of TE include: - Decrease in hair density - Empty hair openings (active telogen phase) - Short vellus hairs (recovery phase)

Question 67

What are the histological findings indicative of Telogen Effluvium?

Answer 67

Histological findings of TE include: - Quantitative assessment of hair count (total hair numbers, terminal vs vellus hair) - Telogen-anagen ratio via horizontal sectioning of a 4 mm punch biopsy at the level between reticular dermis and subcutaneous tissue.

Question 68

What does active shedding indicate in terms of hair loss assessment?

Answer 68

Active shedding is indicated when more than 10% of tested hairs are collected or when more than 5 to 6 hairs are consistently pulled from 2 or more areas.

Question 69

What is the significance of the presence of tapered 'pencil point' hairs in hair loss evaluation?

Answer 69

The presence of tapered 'pencil point' hairs suggests alopecia areata.

Question 70

What is the recommended procedure for conducting a trichogram?

Answer 70

1. Patients should not wash hair for 3 to 5 days before examination. 2. 50 to 100 hairs should be clumped by forceps or needle holder and forcibly plucked. 3. Investigate root morphology in sites 2 cm from the frontline or midline. 4. Collect the telogen-anagen ratio.

Question 71

What does a telogen rate exceeding 25% suggest in hair loss assessment?

Answer 71

A telogen rate exceeding 25% suggests acute Telogen Effluvium (TE).

Question 72

How does trichoscopy assist in the diagnosis of hair disorders?

Answer 72

Trichoscopy is useful for: - Early detection of regrowth of short vellus hairs in the recovery phase of TE. - Distinction between disorders such as TE, AGA, and diffuse AA.

Question 73

What are the signs suggestive of Telogen Effluvium (TE) observed during trichoscopy?

Answer 73

Signs suggestive of TE include: - Decrease in hair density - Empty hair openings (active telogen phase) - Short vellus hairs (recovery phase)

Question 74

What histological findings are indicative of Telogen Effluvium?

Answer 74

Histological findings of TE include: - Quantitative assessment of hair count (total hair numbers, terminal vs vellus hair). - Miniaturization and telogen-anagen ratio via horizontal sectioning of 4 mm punch biopsy at the level between reticular dermis and subcutaneous tissue.

Question 75

What are the key findings in a general examination for telogen effluvium?

Answer 75

Key findings include: - Normal total hair count - Increase in telogen hair ratio (11% on average, 20% can support diagnosis) - Normal hair size - Absence of significant inflammation or fibrotic changes.

Question 76

What are the differential diagnoses for hair loss in telogen effluvium?

Answer 76

The differential diagnoses include: | Condition | Characteristics | |-------------------------------|----------------------------------------------------------------------------------------------------| | Female Pattern Hair Loss | - Affects top of scalp, frontal hairline preserved - Triangular reduction in hair density - Hair pull test and trichogram usually not valuable - Dermoscopic investigation may show hair diameter diversity, peripilar sign, and empty follicles | | Alopecia Areata Incognita | - Acute and diffuse loss of hair without patches - Hair pull test strongly positive - Exclamation point hairs rarely found - Dermoscopy shows yellow dots of various sizes | | Psychogenic Pseudoeffluvium | - Aged 35-50 years in women, under 35 in men - Hair pull test fails to detect hair loss - Associated with body dysmorphic disorder and anxiety |

Question 77

What laboratory examinations are recommended for diagnosing telogen effluvium?

Answer 77

Recommended laboratory examinations include: - Urine analysis - CBC (Complete Blood Count) - ESR (Erythrocyte Sedimentation Rate) - Total protein and albumin - AST, ALT, BUN/Creatinine - LDH - Serum ferritin and zinc - Thyroid hormones (T3, T4, TSH) - ANA, sex hormones, prolactin, CRP, syphilis, and HIV.

Question 78

How would you differentiate alopecia areata incognita from telogen effluvium?

Answer 78

Alopecia areata incognita shows a strongly positive hair pull test with dystrophic roots and yellow dots on dermoscopy, unlike telogen effluvium.

Question 79

How would you differentiate androgenetic alopecia from telogen effluvium?

Answer 79

Androgenetic alopecia shows hair diameter diversity and a preserved frontal hairline, unlike telogen effluvium.

Question 80

What are the key findings in a general examination for diagnosing telogen effluvium?

Answer 80

Key findings include: 1. Normal total hair count 2. Increase in telogen hair ratio (11% on average, 20% can support diagnosis) 3. Normal hair size 4. Absence of significant inflammation or fibrotic changes.

Question 81

How can dermoscopic investigation help differentiate between types of hair loss?

Answer 81

Dermoscopy can help differentiate types of hair loss by identifying: - Hair diameter diversity - Peripilar sign (brown halo around follicular ostium) - Empty follicles.

Question 82

What are the characteristics of Female Pattern Hair Loss?

Answer 82

Characteristics include: - Affects the top of the scalp while preserving the frontal hairline - Triangular reduction in hair density in the frontal scalp resembling a Christmas tree - Hair pull test and trichogram are usually not valuable - Quantitative HPx can confirm diagnosis by adopting a terminal to vellus-like hair ratio.

Question 83

What is the significance of the hair pull test in Alopecia Areata Incognita?

Answer 83

In Alopecia Areata Incognita, the hair pull test is: - Strongly positive, collecting telogen hairs - Exclamation point hairs with dystrophic roots are hardly found - HPx shows peribulbar lymphocyte infiltration.

Question 84

What is the clinical significance of Psychogenic Pseudoeffluvium?

Answer 84

Psychogenic Pseudoeffluvium is clinically significant because: - It typically affects individuals aged 35 to 50 years in women or under 35 in men - HPx fails to detect any evidence of hair loss - It is associated with body dysmorphic disorder and underlying depressive or anxiety disorders.

Question 85

What is the expected outcome for hair regrowth after identifying and eliminating the triggering cause of telogen effluvium?

Answer 85

Normal hair regrowth can be expected within several months once the triggering cause is successfully identified and eliminated.

Question 86

What are the management strategies for telogen effluvium?

Answer 86

The management strategies include: 1. Observation until spontaneous remission 2. Reassurance 3. Psychological support.

Question 87

What are the mechanisms of telogen effluvium in various conditions?

Answer 87

The mechanisms of telogen effluvium vary by condition, including: - Postpartum: Hormonal changes after childbirth - Minoxidil application: Shedding phase due to hair cycle disruption - Febrile illness: Stress response leading to hair loss - Etretinate intake: Medication-induced hair cycle alteration - Stress: Psychological or physical stress triggering hair loss - Chronic telogen effluvium: Persistent triggers leading to prolonged hair loss.

Question 88

What are the mechanisms of telogen effluvium for postpartum, minoxidil application, febrile illness, etretinate intake, stress, and chronic telogen effluvium?

Answer 88

- **Postpartum**: Hormonal changes after childbirth. - **Minoxidil application**: Shedding phase due to hair cycle disruption. - **Febrile illness**: Stress response leading to hair loss. - **Etretinate intake**: Medication-induced hair cycle alteration. - **Stress**: Psychological or physical stress triggering hair loss. - **Chronic telogen effluvium**: Persistent triggers leading to prolonged hair shedding.

Question 89

What are three signs suggestive of telogen effluvium observed on trichoscopy?

Answer 89

1. Increased number of **telogen hairs**. 2. **Miniaturization** of hair follicles. 3. **Peripilar sign** (a halo around the hair follicle).

Question 90

What are the three management strategies for telogen effluvium?

Answer 90

1. Observation until spontaneous remission. 2. Reassurance. 3. Psychological support.

Question 91

Identify the mechanism of telogen in the following conditions: postpartum, minoxidil application, febrile illness, etretinate intake, stress, and chronic telogen effluvium.

Answer 91

- **Postpartum**: Hormonal changes lead to increased telogen phase. - **Minoxidil application**: Can induce a shedding phase as hair follicles transition. - **Febrile illness**: Stress response can push hair into the telogen phase. - **Etretinate intake**: Affects hair cycle, potentially leading to telogen effluvium. - **Stress**: Psychological or physical stress can trigger premature entry into telogen. - **Chronic telogen effluvium**: Persistent factors lead to prolonged telogen phase.

Question 92

On trichoscopy, what are three signs suggestive of telogen effluvium?

Answer 92

1. **Increased number of telogen hairs**: More hairs in the telogen phase than normal. 2. **Miniaturized hairs**: Thinner hairs indicating a disrupted hair cycle. 3. **Peripilar sign**: Presence of a white bulb at the end of the hair shaft, indicating telogen hairs.