What are the common causes of telogen effluvium and can Symbicort (budesonide/formoterol) cause it?

Common Causes of Telogen Effluvium and Symbicort's Potential Role

Symbicort (budesonide/formoterol) is not listed among the common medications known to cause telogen effluvium, and there is no strong evidence linking it to this type of hair loss.

Common Causes of Telogen Effluvium

Telogen effluvium (TE) is one of the most common causes of diffuse, non-scarring hair loss. It occurs when a significant number of hair follicles prematurely enter the telogen (resting) phase of the hair cycle, resulting in excessive shedding. The most common triggers include:

Physiological Stressors

• Childbirth (postpartum telogen effluvium)
• Major surgery
• Severe illness with high fever
• Sudden weight loss or crash dieting
• Emotional or psychological stress

Medical Conditions

• Iron deficiency
• Thyroid disorders (both hypo- and hyperthyroidism)
• Nutritional deficiencies (protein, zinc, vitamin D)
• Chronic illness

Medications

Common medications associated with telogen effluvium include:

• Retinoids
• Antifungal agents
• Psychotropic medications
• Beta-blockers
• Anticoagulants
• Antiepileptics
• Hormonal therapies (including contraceptives)

Diagnosis of Telogen Effluvium

Diagnosis typically involves:

1. Hair pull test: Positive when more than 6 hairs are extracted 1
2. Trichoscopy: Shows hair shaft diameter variation and decreased follicular units 1
3. Laboratory testing: Complete blood count, ferritin levels, thyroid stimulating hormone, and vitamin D levels 1
4. Scalp biopsy: Reveals normal follicular density with increased telogen hair follicles without inflammation 2

Differentiating from Other Hair Loss Conditions

Telogen effluvium must be differentiated from other conditions including:

• Androgenetic alopecia
• Alopecia areata
• Trichotillomania
• Anagen effluvium (drug-induced) 3

Symbicort and Hair Loss

Symbicort, a combination of budesonide (corticosteroid) and formoterol (long-acting beta-agonist), is not specifically mentioned in the literature as a common cause of telogen effluvium. While corticosteroids can potentially affect hair growth in some individuals, Symbicort is primarily an inhaled medication with limited systemic absorption when used as directed.

In a comprehensive review of medication-induced telogen effluvium 4, the primary culprits were identified as systemic retinoids, antifungal agents, and psychotropic medications, with no mention of inhaled corticosteroid/LABA combinations like Symbicort.

Management Approach

If telogen effluvium is suspected:

1. Identify and remove the trigger if possible
2. Treat underlying conditions:
   • Iron supplementation if ferritin levels are low
   • Vitamin D supplementation if deficient 1
3. Consider treatments such as:
   • Topical minoxidil 5% 1
   • Low-level laser therapy as complementary treatment 1

Prognosis

The prognosis for telogen effluvium is generally favorable when the triggering factor is identified and removed. Most cases resolve spontaneously within 3-6 months after elimination of the trigger 1, 5.

Key Points to Remember

• Telogen effluvium typically presents 3-4 months after the triggering event 6
• It is usually self-limiting once the cause is addressed
• Regular monitoring every 3-6 months is recommended to assess response 1
• The psychological impact of hair loss should not be underestimated 1

If hair loss persists beyond 6 months despite addressing potential triggers, consider chronic telogen effluvium or other underlying conditions that may require further investigation.