What is the workup and treatment for telogen effluvium?

Workup and Treatment of Telogen Effluvium

The management of telogen effluvium requires identification and correction of underlying causes, with laboratory testing for ferritin, vitamin D, thyroid function, and complete blood count being essential components of the initial workup. 1, 2

Diagnostic Evaluation

Clinical Assessment

• Pattern of hair loss: Diffuse shedding rather than localized pattern 1
• Hair pull test: Positive when more than 6 hairs are extracted, indicating active shedding 1
• Dermoscopy: Can reveal empty follicles, absence of inflammation, and uniform hair shaft diameter 1
• Trichodynia: Assess for scalp pain or discomfort, which may be present in some patients 3

Laboratory Workup

• Essential tests:

  • Complete blood count (CBC)
  • Serum ferritin (most frequently performed test - 82.3% of cases) 2
  • Thyroid stimulating hormone (TSH)
  • Vitamin D 25-OH levels 1, 4, 2

• Additional tests based on clinical suspicion:

  • Vitamin B12 (deficiency found in 30.7% of patients) 2
  • Zinc levels (deficiency found in 2.1% of patients) 2
  • Folate (deficiency found in 4.4% of patients) 2

Differential Diagnosis

Must distinguish telogen effluvium from:

• Alopecia areata (shows exclamation mark hairs)
• Trichotillomania (broken hairs firmly anchored)
• Tinea capitis (inflammation and scaling)
• Androgenetic alopecia (different pattern of hair loss) 1, 5

Treatment Approach

1. Identify and Address Underlying Causes

• Nutritional deficiencies: Replace deficient nutrients

  • Iron supplementation (most common treatment - 37.5% of prescriptions) 2
  • Vitamin D supplementation (72.2% of patients have deficiency) 2
  • Vitamin B12, zinc, or folate if deficient 4, 2

• Other common triggers to identify and address:

  • Medications (review and modify if possible)
  • Physical or emotional stress
  • Recent illness (including post-COVID-19) 6
  • Hormonal changes
  • Thyroid dysfunction (present in 4.6% of patients) 2

2. Pharmacological Treatment

• Oral minoxidil: Low-dose (0.25-2.5 mg daily) has shown efficacy in reducing hair shedding scores in chronic telogen effluvium 3

  • Significant reduction in hair shedding at 6 months (p<0.001) and 12 months (p<0.001)
  • Side effects include facial hypertrichosis (36%), postural dizziness (transient), and ankle edema (rare)

• Topical minoxidil 5%: FDA-approved for men and women with high strength of evidence 1

• Topical corticosteroids: May help if inflammation is present (strength of recommendation C) 1

3. Supportive Care

• Documentation: Photograph affected areas and map distribution of hair loss to establish baseline 1
• Psychological support: Consider counseling for patients distressed by hair loss 1
• Patient education: Explain the typically self-limiting nature of acute telogen effluvium

Monitoring and Follow-up

• Regular follow-up to assess treatment response
• Repeat laboratory tests if deficiencies were identified initially
• Reassess at 3-6 month intervals (improvement in trichodynia may occur within 3 months) 3

Prognosis

• Acute telogen effluvium typically resolves within 6 months if the trigger is removed
• Chronic telogen effluvium (>6 months) may require longer treatment
• Treatment response varies based on underlying cause and duration of condition

Common Pitfalls to Avoid

• Failing to perform adequate laboratory testing, particularly for ferritin and vitamin D
• Overlooking thyroid dysfunction as a potential cause
• Not addressing psychological impact of hair loss
• Expecting immediate results from treatment (improvement typically takes 3-6 months)
• Confusing telogen effluvium with other causes of hair loss, particularly early female pattern hair loss