What are the triggers for telogen effluvium?

Triggers for Telogen Effluvium

Common triggers for telogen effluvium include childbirth, major surgery, severe illness, sudden weight loss, emotional stress, iron deficiency, thyroid disorders, nutritional deficiencies, chronic illness, and certain medications such as retinoids, antifungal agents, and hormonal therapies. 1

Understanding Telogen Effluvium

Telogen effluvium (TE) is one of the most common causes of diffuse, non-scarring hair loss characterized by excessive shedding of hair. It occurs when a significant number of hair follicles prematurely enter the telogen (resting) phase of the hair cycle, resulting in increased hair shedding typically noticed 3-4 months after the triggering event 2.

Specific Triggers of Telogen Effluvium

Physiological Triggers

• Childbirth/Postpartum period - A well-established cause of acute TE
• Major surgery - Surgical stress can shift hair follicles into telogen phase
• Severe illness - Particularly those with high fever or systemic involvement

Nutritional Factors

• Iron deficiency - The most common nutritional deficiency associated with chronic telogen hair loss 1
• Sudden weight loss - Particularly with crash dieting or malnutrition
• Protein malnutrition - Essential for hair follicle growth and maintenance
• Zinc deficiency - Important for cellular division and protein synthesis
• Vitamin D deficiency - Associated with hair loss and plays a role in normal hair follicle function 1

Psychological Factors

• Emotional stress - Acute or chronic psychological stress can trigger TE
• Anxiety and depression - May contribute to or exacerbate hair shedding

Medical Conditions

• Thyroid disorders - Both hypothyroidism and hyperthyroidism
• Chronic illness - Various systemic diseases can trigger TE
• Autoimmune conditions - May contribute to hair loss through various mechanisms

Medication-Induced Triggers 3

• Retinoids - Including isotretinoin and acitretin
• Antifungal agents - Particularly ketoconazole and other azoles
• Hormonal therapies - Including hormonal contraceptives and hormone replacement therapy
• Psychotropic medications - Antidepressants, mood stabilizers, and antipsychotics
• Anticoagulants - Particularly heparin and warfarin
• Beta-blockers - Can cause hair loss in some individuals

Diagnostic Approach

When evaluating a patient with suspected telogen effluvium:

1. Detailed timeline assessment:

   • Identify potential triggers 3-4 months before onset of hair shedding
   • Determine if acute (<6 months) or chronic (>6 months) in nature

2. Laboratory testing 1:

   • Complete blood count
   • Ferritin levels (iron stores)
   • Thyroid stimulating hormone
   • Vitamin D 25OH levels
   • Consider additional tests based on clinical suspicion

3. Diagnostic tests:

   • Hair pull test - Positive when >10% of pulled hairs come out easily
   • Trichoscopy - To rule out other causes of hair loss
   • Scalp biopsy - May be needed in unclear cases

Management Approach

The cornerstone of treatment is identifying and removing the trigger 1:

1. Address underlying causes:

   • Correct nutritional deficiencies with appropriate supplementation
   • Manage underlying medical conditions
   • Consider medication changes if drug-induced

2. Supportive treatments:

   • Topical minoxidil 5% may help accelerate recovery
   • Low-level laser therapy as a complementary approach
   • For chronic cases, oral minoxidil has shown promise in reducing hair shedding 4

Clinical Pearls and Pitfalls

• Delayed presentation: Hair shedding typically occurs 3-4 months after the triggering event, making identification of the cause challenging
• Multiple triggers: Patients may have more than one contributing factor
• Trichodynia: Some patients experience scalp pain or discomfort that may improve with treatment 4
• Psychological impact: Hair loss can significantly affect quality of life and may require psychological support
• Prognosis: Most cases of acute TE resolve spontaneously within 6 months after trigger removal, but chronic TE may persist for years

Remember that telogen effluvium is generally reversible once the underlying trigger is identified and addressed, though recovery may take several months as the hair cycle normalizes.