What is the best treatment approach for a patient with chronic telogen effluvium (excessive hair shedding), considering potential underlying conditions such as hypothyroidism or iron deficiency anemia?

Treatment for Chronic Telogen Effluvium

The primary treatment for chronic telogen effluvium is identifying and correcting underlying nutritional deficiencies—particularly iron deficiency and thyroid disorders—followed by oral minoxidil (0.25-2.5 mg daily) if conservative measures fail. 1, 2

Initial Diagnostic Workup

Before initiating treatment, obtain the following laboratory tests in all patients with chronic telogen effluvium:

• Serum ferritin (target >100 μg/L, as levels up to 100 μg/L may still reflect iron deficiency in the presence of inflammation) 3
• Iron indices including transferrin saturation 3
• Thyroid function tests (TSH, T3, T4) 2
• Complete blood count 2

These tests are essential because iron deficiency and thyroid disorders are the two most common treatable causes of diffuse hair loss, often without obvious clinical features 2.

Iron Replacement Strategy

Oral Iron Therapy

Start with oral iron supplementation as first-line therapy for documented iron deficiency:

• Ferrous sulfate is preferred as the least expensive formulation with no advantage of other preparations 3
• Dose once daily at most (no more than 100 mg elemental iron daily in inactive disease) 3
• Every-other-day dosing may improve tolerance with similar absorption rates 3
• Add vitamin C to enhance iron absorption 3

Monitor response at 1 month: expect hemoglobin rise of ≥1.0 g/dL and normalization of ferritin and transferrin saturation 3. Continue iron supplementation for 3 months after correction of anemia to replenish body stores 3.

Intravenous Iron Therapy

Switch to IV iron if:

• Oral iron is not tolerated after trying at least two different preparations 3
• No improvement in ferritin levels after adequate oral trial 3
• Severe anemia at presentation 3
• Active inflammation compromising absorption 3

IV iron dosing: Use total iron deficit calculation (Ganzoni formula) or empiric 1 gram total dose with interval reassessment 3. Prefer formulations requiring only 1-2 infusions 3.

Pharmacologic Treatment

Oral Minoxidil

For patients with persistent chronic telogen effluvium despite correction of nutritional deficiencies:

• Start at 0.25-2.5 mg once daily 1
• Expected response: Reduction in hair shedding scores by 1.7 points at 6 months and 2.58 points at 12 months 1
• Trichodynia improvement occurs within 3 months in patients with scalp pain 1

Monitor for adverse effects:

• Blood pressure changes (minimal: -0.5 mmHg systolic, +2.1 mmHg diastolic on average) 1
• Transient postural dizziness (resolves with continued treatment) 1
• Facial hypertrichosis (occurs in approximately 36% of patients; manageable with waxing or laser hair removal) 1
• Ankle edema (rare) 1

Topical Minoxidil

Topical minoxidil 2% can be used as an alternative, particularly if chronic telogen effluvium overlaps with female pattern hair loss 2.

Adjunctive Treatments

Nutritional Supplementation

Consider oral supplementation containing:

• Sulfurated amino acids (L-cystine, L-methionine, liposomal glutathione) 4
• Trace elements (zinc, copper, iron, selenium) 4
• Ubidecarenone and vitamin B5 4

This combination showed clinical healing in 70% of patients and good improvement in 30% at 6 months 4.

Platelet-Rich Plasma (PRP)

PRP therapy (4 monthly sessions) may be considered for refractory cases, showing significant improvement in hair density and thickness at 3 months with excellent safety profile 5. Both expensive specialized PRP kits and ordinary low-cost laboratory tubes centrifuged at 1000 rpm show comparable efficacy 5.

Important Clinical Considerations

Differentiate chronic telogen effluvium from female pattern hair loss:

• Chronic telogen effluvium shows normal scalp histology on biopsy 2
• Female pattern hair loss shows miniaturization with terminal:vellus ratio <4:1 2
• This distinction is critical as treatment approaches differ 2

Patient counseling is essential:

• Reassure that chronic telogen effluvium represents excessive shedding, not actual hair loss 2
• Explain it does not lead to baldness 2
• Set realistic expectations: spontaneous resolution may take 3-10 years 2
• With treatment, most patients complete 12 months successfully 1

Avoid common pitfalls:

• Do not use oral iron in patients with active systemic inflammation, as absorption is inhibited 3
• Ferritin can be falsely elevated as an acute phase reactant during inflammation 6
• In patients with ongoing blood loss, regularly-scheduled iron infusions may be needed 3