What is telogen effluvium in a patient with hypozincemia on immunosuppressive therapy, including corticosteroids like prednisone (corticosteroid), and how is it managed?

Telogen Effluvium: Definition and Management

Telogen effluvium is a common scalp disorder characterized by excessive, diffuse shedding of hair triggered by physiological or emotional stress, drugs, trauma, or nutritional deficiencies, resulting from premature shifting of hair follicles from the growth phase into the resting (telogen) phase. 1, 2

Clinical Definition and Pathophysiology

Telogen effluvium represents one of the most common causes of non-scarring alopecia, presenting as sudden excessive hair loss that can significantly impact quality of life despite its typically self-limited nature 1, 2. The condition occurs when multiple hair follicles are prematurely pushed into the telogen (resting) phase of the hair cycle, leading to synchronous shedding approximately 2-3 months after the triggering event 1.

Key Precipitating Factors in Your Clinical Context

Corticosteroid-Related Mechanisms

• Corticosteroids like prednisone can directly trigger telogen effluvium through multiple mechanisms, including metabolic stress on hair follicles and disruption of normal hair cycling 1
• Immunosuppressive therapy creates physiological stress that commonly precipitates hair shedding 1, 2

Hypozincemia as a Contributing Factor

• Zinc deficiency has a non-trivial prevalence in telogen effluvium patients and justifies routine laboratory evaluation 3
• The greater Pittsburgh cross-sectional study demonstrated that zinc deficiency rates warrant inclusion in initial clinical workup for all telogen effluvium cases 3

Diagnostic Approach

Clinical Presentation

• Patients typically report sudden, diffuse hair shedding with increased hair loss during washing or brushing 1
• Trichodynia (scalp pain or tenderness) may accompany the hair loss 1
• Symptoms usually appear 2-3 months after the triggering stressor 2

Diagnostic Testing

• Hair wash test: Quantifies daily hair shedding 1
• Trichogram: Evaluates the percentage of telogen hairs (>20% suggests telogen effluvium) 1
• Phototrichogram: Provides objective measurement of hair density and growth 1
• Scalp biopsy: Reserved for unclear cases, shows increased telogen:anagen ratio 1

Essential Laboratory Workup

Given your patient's hypozincemia, the following labs are justified:

• Zinc levels (already identified as deficient) 3
• Ferritin levels (deficiency prevalence is non-trivial) 3
• Vitamin D levels (commonly deficient in telogen effluvium) 3
• Vitamin B12 and folate (consider based on clinical history) 3

Management Strategy

Primary Intervention: Remove Causative Factors

The most critical component of management is identifying and correcting the underlying trigger 1, 2. In your patient:

• Evaluate whether corticosteroid dose can be reduced or tapered (balance against immunosuppression needs)
• Correct hypozincemia with zinc supplementation 3, 4

Pharmacologic Treatment Options

First-Line Nutritional Supplementation

For patients with documented zinc deficiency, zinc supplementation combined with arginine, L-cystine, and vitamin B6 has demonstrated efficacy 4. The Cystiphane® study showed:

• Mean clinical improvement rating of 2.89/5 by clinicians 4
• Trichoscopic hair quantity improvement of +2.055 4
• Hair diameter improvement of +1.83 4
• Dosing: 4 tablets daily for 3 months 4

Corticosteroid Considerations

• Topical or intralesional corticosteroids can be used for telogen effluvium treatment, though this creates a clinical paradox in your patient already on systemic corticosteroids 1
• The benefit must be weighed against the fact that systemic corticosteroids may be contributing to the condition

Minoxidil

• Minoxidil can accelerate recovery and promote hair regrowth 1
• Consider as adjunctive therapy while addressing underlying causes

Novel Therapies

• Single-session botulinum toxin A injection showed equivalent efficacy to multiple mesotherapy sessions with minimal side effects and better patient compliance 5
• Multivitamin mesotherapy (multiple sessions) is an alternative but requires more frequent visits 5

Clinical Pitfalls to Avoid

• Do not delay zinc repletion in documented hypozincemia—this is a reversible, treatable cause 3
• Avoid attributing all hair loss to corticosteroids without evaluating for nutritional deficiencies 3
• Remember that telogen effluvium is typically self-limited and reversible once triggers are removed 2
• The multifactorial nature means multiple simultaneous interventions (zinc repletion + trigger removal + possible minoxidil) may be needed 2

Expected Timeline

• Hair shedding typically continues for 3-6 months after trigger removal 2
• Regrowth becomes visible 3-6 months after successful intervention 1
• Reassure patients that remission rates are high once causative factors are addressed 2