What is the treatment for Telogen Effluvium?

Treatment of Telogen Effluvium

The primary treatment for telogen effluvium is identifying and removing the causative factor, with spontaneous remission occurring in up to 80% of cases with short duration (<1 year), making watchful waiting a legitimate first-line approach. 1, 2

Immediate Management Steps

1. Identify and Remove Triggering Factors

• Medication review is critical: Discontinue or substitute medications known to cause telogen effluvium, including systemic retinoids, antifungal agents, psychotropic medications, anticoagulants, and antihypertensive drugs. 3, 4
• Address physiologic stressors: Recent illness, surgery, childbirth, severe emotional stress, or rapid weight loss are common triggers that resolve spontaneously once the stressor is removed. 5, 6
• Evaluate nutritional deficiencies: Check serum ferritin, vitamin D, zinc, and folate levels, as these deficiencies are non-trivial in telogen effluvium patients. 7, 2

2. Nutritional Supplementation (When Deficiencies Identified)

• Iron supplementation: Address low ferritin levels, as iron deficiency is the most common nutritional deficiency worldwide and a sign of chronic diffuse telogen hair loss. 5
• Vitamin D supplementation: Correct deficiency (defined as <20 ng/mL), which shows strong association with hair loss. 5
• Zinc supplementation: Replace if serum zinc levels are low, as zinc serves as a cofactor for multiple enzymes involved in hair follicle function. 5

Important caveat: While nutritional deficiencies are associated with telogen effluvium, routine supplementation without documented deficiency has not been proven effective. 7

Pharmacologic Treatment Options

For Chronic Telogen Effluvium (>6 months duration)

• Oral minoxidil (0.25-2.5 mg daily) is the most evidence-based pharmacologic option, showing significant reduction in hair shedding scores at 6 months (mean reduction 1.7, p<0.001) and 12 months (mean reduction 2.58, p<0.001). 8
  • Dosing: Start at 0.25-0.5 mg daily and titrate based on response and tolerability
  • Expected timeline: Improvement in trichodynia (scalp pain) within 3 months; reduction in shedding by 6 months
  • Side effects to monitor: Facial hypertrichosis (36% of patients), transient postural dizziness (5.6%), ankle edema (2.8%) 8
  • Blood pressure monitoring: Mean change is minimal (−0.5 mmHg systolic, +2.1 mmHg diastolic) 8

Alternative Pharmacologic Options

• Topical minoxidil: While primarily studied for androgenetic alopecia, may be considered for chronic telogen effluvium, though oral formulation shows better compliance. 8
• Corticosteroids: May be used if inflammatory component is suspected, though evidence is limited for pure telogen effluvium. 6
• Novel treatments: CNPDA (caffeine, niacinamide, panthenol, dimethicone, and an acrylate polymer) has been proposed but lacks robust evidence. 6

Diagnostic Workup to Guide Treatment

• Hair wash test, trichogram, or phototrichogram: Confirm increased telogen shedding (>20% telogen hairs). 6
• Scalp biopsy: Reserve for cases where diagnosis is uncertain or to rule out miniaturization suggesting androgenetic alopecia. 6
• Laboratory testing: TSH (rule out thyroid disease), ferritin, vitamin D, zinc, folate. 2, 5

Management Algorithm

1. Acute telogen effluvium (<6 months): Watchful waiting with trigger removal is appropriate, as 80% resolve spontaneously. 1, 2
2. Chronic telogen effluvium (>6 months): Consider oral minoxidil 0.25-2.5 mg daily after correcting nutritional deficiencies. 8, 2
3. Persistent cases: Re-evaluate for misdiagnosis (androgenetic alopecia, diffuse alopecia areata) with scalp biopsy. 6

Common Pitfalls to Avoid

• Over-supplementation without documented deficiency: Routine vitamin/mineral supplementation without laboratory confirmation is not evidence-based. 7
• Premature treatment: Many cases resolve spontaneously within 6-12 months; aggressive treatment may not be necessary. 1
• Misdiagnosis: Diffuse alopecia areata and early androgenetic alopecia can mimic telogen effluvium—biopsy when uncertain. 6, 5
• Ignoring psychological impact: Address anxiety and depression related to hair loss as part of comprehensive management. 2