86: Telogen Effluvium Flashcards
What is telogen effluvium and how is it characterized?
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.
What are the common causes of telogen effluvium?
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.
What demographic is most likely to suffer from acute telogen effluvium?
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.
What is the clinical significance of increased hair shedding in telogen effluvium?
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.
What are the different types of telogen effluvium?
Telogen effluvium is subdivided into: 1. Acute telogen effluvium 2. Chronic diffuse telogen hair loss 3. Chronic telogen effluvium
How would you differentiate between telogen effluvium and anagen effluvium?
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.
What is the mechanism of hair shedding after starting minoxidil?
The mechanism is immediate telogen release due to accelerated exogen. Counsel the patient that this is temporary and regrowth will follow.
What are the primary characteristics of telogen effluvium and its subtypes?
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.
What is the pathogenesis of immediate anagen release in telogen effluvium?
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.
How does the epidemiology of telogen effluvium differ among various demographics?
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.
What are the clinical implications of delayed anagen release in telogen effluvium?
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.
What is the most representative manifestation of telogen effluvium regardless of subtype?
The most representative manifestation of telogen effluvium is diffuse excessive shedding of club hairs without an enclosing sac and pigmentation.
What is the typical shedding timeline for acute telogen effluvium?
Shedding in acute telogen effluvium is noted 2 to 4 months from causative events, with regrowth expected by 3 to 6 months.
What are the characteristics of shedding in newborns related to telogen effluvium?
In newborns, shedding starts within 4 months after birth, is completed before the first 6 months of life, and involves 60-80% telogen hair.
What causes immediate anagen release in febrile illness?
Immediate anagen release in febrile illness is caused by high fever, which can stress hair-producing matrix cells and lead to early anagen release.
What is the timeline for delayed anagen release postpartum?
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.
What is the likely mechanism of hair shedding 3 months after a febrile illness?
The likely mechanism is immediate anagen release due to physiologic stress on hair-producing matrix cells. Shedding starts 3-4 months after the illness.
What is the underlying mechanism of hair shedding 2 months after childbirth?
The mechanism is delayed anagen release, where the anagen period is prolonged during pregnancy and terminated postpartum. Regrowth is expected within 3-6 months.
What is the likely mechanism of hair shedding after surgery?
The mechanism is immediate anagen release due to surgical stress. Manage with reassurance and observation.
What are the characteristics of acute telogen effluvium?
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.
How does febrile illness lead to immediate anagen release?
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.
What are the implications of surgery on hair shedding patterns?
Surgery can lead to telogen effluvium due to factors such as fever, general anesthesia, and changes in hormones and nutrition levels.
What is the significance of delayed anagen release in postpartum alopecia?
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.
What is the expected timeline for hair shedding and recovery after initiating medications that cause immediate anagen release?
Shedding starts 2 to 3 months after initiation of medication, and recovery can be expected 3 months after termination.
What are some common drugs associated with immediate anagen release?
Common drugs include anticoagulants, anti-infective agents, cardiovascular drugs, psychotropics, oral contraceptive pills (OCPs), and retinoids.
What is the relationship between thyroid disease and hair regrowth?
Hair regrowth can be observed around 8 weeks after initiation of thyroid hormone replacement in patients with hypothyroidism.
How does aging affect hair loss?
Aging is associated with diffuse hair loss in the scalp and body, along with a histopathologic increase in the telogen ratio.
What are the implications of zinc deficiency on hair health?
Zinc deficiency can lead to conditions such as acrodermatitis enteropathica, characterized by hair loss, dermatitis, diarrhea, immunodeficiency, and growth retardation.
What dietary factors can contribute to chronic diffuse telogen hair loss?
Chronic diffuse telogen hair loss can be influenced by malnutrition, particularly in protein-deficient elderly subjects and children with protein-calorie malnutrition.
What is the significance of serum ferritin levels in relation to hair loss?
Serum ferritin levels below 40 mg/dl indicate iron deficiency, which is controversial in its direct impact on hair loss.
What is the likely cause of diffuse hair loss with a history of rapid weight loss?
The likely cause is telogen effluvium due to caloric restriction or malnutrition. Management includes nutritional counseling.
What clinical features and management would you expect in a patient with diffuse hair loss and zinc deficiency?
Clinical features include hair loss, dermatitis, and diarrhea. Management involves zinc supplementation.
What is the likely diagnosis for hair shedding after a crash diet?
The likely diagnosis is telogen effluvium due to caloric restriction. Management includes restoring adequate nutrition.
How would you confirm and manage hair loss in a patient with thyroid dysfunction?
Confirm with thyroid function tests showing hypothyroidism. Manage with thyroid hormone replacement.
What are the implications of acquired zinc deficiency on hair loss?
Acquired zinc deficiency can lead to hair loss and is associated with conditions like acrodermatitis enteropathica.
What dietary factors can contribute to chronic telogen effluvium in elderly patients?
Protein-calorie malnutrition in elderly subjects can lead to chronic telogen effluvium.
What systemic illnesses are associated with telogen effluvium?
Systemic illnesses associated with telogen effluvium include lymphoproliferative disease, advanced malignancy, collagen diseases, hepatic disease, chronic renal failure, systemic amyloidosis, and inflammatory bowel disease.
What are the characteristics of chronic telogen effluvium?
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.
What diagnostic criteria should be considered for telogen effluvium?
Diagnostic criteria for telogen effluvium include hair examination, hair loss count, and hair pull test.
What are some potential triggers for telogen effluvium?
Potential triggers for telogen effluvium include systemic illness, psychological stress, biotin or fatty acid deficiency, exposure to heavy metals, and sunlight.
What diagnostic steps should be taken for a patient with diffuse hair shedding for 7 months?
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.
What condition should you suspect in a 50-year-old woman with diffuse hair loss and bitemporal recession?
Suspect chronic telogen effluvium. Confirm with a trichogram showing prolonged anagen duration.
How does systemic lupus erythematosus (SLE) contribute to telogen effluvium?
SLE contributes to telogen effluvium through systemic inflammation and potential medication side effects.
What is the likely mechanism of hair shedding in a patient with chronic renal failure?
The mechanism is systemic illness-induced telogen effluvium. Perform a hair pull test and laboratory tests for renal function.
How would you confirm and treat hair loss in a patient with biotin deficiency?
Confirm with laboratory tests showing low biotin levels. Treat with biotin supplementation.
What is the likely cause of diffuse hair loss in a patient with a history of UV exposure?
The likely cause is telogen effluvium due to UV-induced damage. Confirm with a trichogram showing increased telogen hairs.
What is the mechanism of hair loss in a patient with HIV?
The mechanism is immediate anagen release due to systemic illness. Manage by addressing the underlying HIV infection.
What diagnostic tests would you perform for a patient with diffuse hair loss and heavy metal exposure?
Perform laboratory tests for heavy metals like arsenic, thallium, and selenium.
What is the likely mechanism of diffuse hair loss in a patient with HIV?
The mechanism is immediate anagen release due to systemic illness. Manage by addressing the underlying HIV infection and providing supportive care.
What diagnostic tests should be performed for diffuse hair loss with a history of heavy metal exposure?
Perform laboratory tests for heavy metals like arsenic, thallium, and selenium. Confirm with a trichogram showing increased telogen hairs.
What is the likely diagnosis for diffuse hair loss in a patient with eosinophilia-myalgia syndrome?
The likely diagnosis is telogen effluvium due to systemic illness. Confirm with a trichogram and laboratory tests for eosinophilia.
What is the likely mechanism for diffuse hair loss in a patient with collagen disease?
The mechanism is systemic inflammation-induced telogen effluvium. Perform a hair pull test, trichogram, and laboratory tests for collagen disease markers.
What is the likely cause of diffuse hair loss in a patient with pancreatitis?
The likely cause is telogen effluvium due to systemic illness. Confirm with a trichogram showing increased telogen hairs.
What is the likely mechanism of diffuse hair loss in a patient with contact dermatitis?
The mechanism is telogen effluvium due to inflammatory damage. Manage by avoiding the irritant and providing supportive care.
What is the likely diagnosis for diffuse hair loss in a patient with systemic amyloidosis?
The likely diagnosis is telogen effluvium due to systemic illness. Confirm with a trichogram and laboratory tests for amyloidosis markers.
What are the potential systemic illnesses associated with chronic telogen effluvium?
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)
What psychological factor is controversially linked to immediate anagen release in hair loss?
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.
What distinguishes chronic telogen effluvium from other forms of hair loss?
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.
What diagnostic criteria should be considered when suspecting telogen effluvium?
When suspecting telogen effluvium, the following diagnostic criteria should be considered:
- Hair appearance: Assessment of global hair thickness and part width.
- Hair loss count: Daily telogen hair loss varies, with a gold standard of more than 100 being abnormal.
- 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).
What indicates active shedding in hair loss assessment?
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.
What is the significance of tapered ‘pencil point’ hairs in hair loss evaluation?
The presence of tapered ‘pencil point’ hairs suggests alopecia areata.
What is the normal telogen-anagen ratio in hair loss assessment?
Normal values for the telogen-anagen ratio are between 4 to 20%, with an average of 13%.
What does a telogen rate exceeding 25% indicate?
A telogen rate exceeding 25% suggests acute Telogen Effluvium (TE).
What is the purpose of a trichogram in hair loss diagnosis?
A trichogram is used to assess hair root morphology and collect the telogen-anagen ratio, which helps in diagnosing hair loss conditions.
What is the difference between phototrichogram and trichoscan?
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 |
What signs are suggestive of Telogen Effluvium (TE) during trichoscopy?
Signs suggestive of TE include:
- Decrease in hair density
- Empty hair openings (active telogen phase)
- Short vellus hairs (recovery phase)
What are the histological findings indicative of Telogen Effluvium?
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.
What does active shedding indicate in terms of hair loss assessment?
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.
What is the significance of the presence of tapered ‘pencil point’ hairs in hair loss evaluation?
The presence of tapered ‘pencil point’ hairs suggests alopecia areata.
What is the recommended procedure for conducting a trichogram?
- Patients should not wash hair for 3 to 5 days before examination.
- 50 to 100 hairs should be clumped by forceps or needle holder and forcibly plucked.
- Investigate root morphology in sites 2 cm from the frontline or midline.
- Collect the telogen-anagen ratio.
What does a telogen rate exceeding 25% suggest in hair loss assessment?
A telogen rate exceeding 25% suggests acute Telogen Effluvium (TE).
How does trichoscopy assist in the diagnosis of hair disorders?
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.
What are the signs suggestive of Telogen Effluvium (TE) observed during trichoscopy?
Signs suggestive of TE include:
- Decrease in hair density
- Empty hair openings (active telogen phase)
- Short vellus hairs (recovery phase)
What histological findings are indicative of Telogen Effluvium?
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.
What are the key findings in a general examination for telogen effluvium?
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.
What are the differential diagnoses for hair loss in telogen effluvium?
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 |
What laboratory examinations are recommended for diagnosing telogen effluvium?
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.
How would you differentiate alopecia areata incognita from telogen effluvium?
Alopecia areata incognita shows a strongly positive hair pull test with dystrophic roots and yellow dots on dermoscopy, unlike telogen effluvium.
How would you differentiate androgenetic alopecia from telogen effluvium?
Androgenetic alopecia shows hair diameter diversity and a preserved frontal hairline, unlike telogen effluvium.
What are the key findings in a general examination for diagnosing telogen effluvium?
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.
How can dermoscopic investigation help differentiate between types of hair loss?
Dermoscopy can help differentiate types of hair loss by identifying:
- Hair diameter diversity
- Peripilar sign (brown halo around follicular ostium)
- Empty follicles.
What are the characteristics of Female Pattern Hair Loss?
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.
What is the significance of the hair pull test in Alopecia Areata Incognita?
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.
What is the clinical significance of Psychogenic Pseudoeffluvium?
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.
What is the expected outcome for hair regrowth after identifying and eliminating the triggering cause of telogen effluvium?
Normal hair regrowth can be expected within several months once the triggering cause is successfully identified and eliminated.
What are the management strategies for telogen effluvium?
The management strategies include:
- Observation until spontaneous remission
- Reassurance
- Psychological support.
What are the mechanisms of telogen effluvium in various conditions?
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.
What are the mechanisms of telogen effluvium for postpartum, minoxidil application, febrile illness, etretinate intake, stress, and chronic telogen effluvium?
- 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.
What are three signs suggestive of telogen effluvium observed on trichoscopy?
- Increased number of telogen hairs.
- Miniaturization of hair follicles.
- Peripilar sign (a halo around the hair follicle).
What are the three management strategies for telogen effluvium?
- Observation until spontaneous remission.
- Reassurance.
- Psychological support.
Identify the mechanism of telogen in the following conditions: postpartum, minoxidil application, febrile illness, etretinate intake, stress, and chronic telogen effluvium.
- 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.
On trichoscopy, what are three signs suggestive of telogen effluvium?
- Increased number of telogen hairs: More hairs in the telogen phase than normal.
- Miniaturized hairs: Thinner hairs indicating a disrupted hair cycle.
- Peripilar sign: Presence of a white bulb at the end of the hair shaft, indicating telogen hairs.
