What is the diagnosis and treatment for a postpartum woman with diffuse hair loss, particularly on the sides of the scalp, 8 weeks after delivery?

Postpartum Telogen Effluvium

This is postpartum telogen effluvium, a self-limited condition that requires reassurance and patient education rather than active treatment. 1, 2

Diagnosis

This clinical presentation is classic for postpartum telogen effluvium:

• Diffuse hair shedding beginning 2-5 months after delivery (this patient is 8 weeks postpartum, which fits the typical 2-3 month onset window) 2, 3
• Increased shedding with showering and brushing, representing normal telogen (resting phase) hairs being shed 4
• Evidence of new hair growth on examination, confirming the hair cycle is recovering 1
• No scalp inflammation, erythema, or induration, ruling out inflammatory causes like alopecia areata or infectious etiologies 1
• Bitemporal and lateral scalp involvement is characteristic of postpartum telogen effluvium 5

The mechanism involves pregnancy-induced prolongation of the anagen (growth) phase, followed by synchronized shift of follicles into telogen phase postpartum, resulting in dramatic shedding 2-3 months later 6, 7.

Management Approach

The primary management is reassurance and education, as spontaneous remission occurs in up to 80% of cases within 3-6 months without treatment. 5, 4

Essential Patient Counseling

• Explain that this represents excessive shedding, not actual permanent hair loss, and it will not lead to baldness 4
• Hair regrowth typically begins 2-3 months after delivery and grows at approximately 1 cm/month 5
• The condition is self-limited and resolves in 3-6 months in most cases 4
• Over 90% of postpartum women experience some degree of hair loss, making this an extremely common physiologic phenomenon 3

Selective Laboratory Testing

While most cases require no testing, consider the following if the clinical picture is atypical or hair loss persists beyond 6 months:

• Serum ferritin (iron deficiency is the most common nutritional deficiency associated with chronic diffuse hair loss) 1
• TSH and free T4 (thyroid dysfunction can cause diffuse hair loss and may not have obvious clinical features) 1, 4
• Vitamin D level (deficiency shows strong association with hair loss, with 70% of alopecia patients deficient versus 25% of controls) 1
• Zinc level (tends to be lower in patients with persistent hair loss) 1

When NOT to Order Extensive Testing

• Do not order excessive laboratory tests when the diagnosis is clinically evident (postpartum timing, diffuse pattern, evidence of regrowth, normal scalp examination) 1
• Investigations are unnecessary in typical postpartum telogen effluvium 5

Treatment Considerations

No specific treatment has been studied well enough to justify routine recommendation for postpartum telogen effluvium. 2

What Does NOT Work

• Thyroid supplementation, topical progesterone/estradiol lotions, and oral contraceptives have been studied but all available studies have significant limitations (small sample size, no control groups, subjective outcomes) and cannot be recommended 2, 6

Nutritional Supplementation (Only If Deficient)

• Vitamin D supplementation for levels <20 ng/mL may be beneficial, though no double-blind trials have examined this specifically for postpartum hair loss 1
• Zinc supplementation when deficient may contribute to hair health 1
• Iron supplementation if ferritin is low should be considered 1

Red Flags Requiring Different Diagnosis

Reconsider the diagnosis if:

• Patchy rather than diffuse hair loss (suggests alopecia areata) 1
• Scalp erythema, scaling, or induration (suggests inflammatory or infectious causes like tinea capitis) 1
• Exclamation mark hairs (short broken hairs around expanding patches, pathognomonic for alopecia areata) 1
• Scarring or permanent hair loss (suggests scarring alopecia requiring biopsy) 1
• Hair loss persisting beyond 12 months postpartum (may represent chronic telogen effluvium or female pattern hair loss requiring different management) 4

Prognostic Factors

• Longer-term breastfeeding correlates with more pronounced postpartum hair loss (adjusted OR 5.96-6.37 for breastfeeding >6 months) 3
• Preterm labor is an independent predictor of postpartum hair loss 3
• Average timeline: onset at 2.9 months, peak at 5.1 months, resolution by 8.1 months postpartum 3

Common Pitfalls to Avoid

• Failing to address the psychological impact of hair loss, which can cause significant anxiety despite being physiologic 1
• Prescribing unproven treatments when reassurance and time are the appropriate management 2
• Missing alternative diagnoses by not examining the scalp carefully for signs of inflammation, scarring, or patchy involvement 1