What is the recommended treatment for a patient with telogen effluvium?

Telogen Effluvium Treatment

The primary management of telogen effluvium is reassurance and patient education, as spontaneous remission occurs in up to 80% of cases within 3-6 months without any treatment, with hair regrowth typically beginning 2-3 months after the triggering event and growing at approximately 1 cm/month. 1

Initial Management Approach

• Reassurance is the cornerstone of treatment because the condition is self-limited in the vast majority of patients, with recovery expected within 6 months 1, 2
• Address the psychological impact of hair loss, as this can significantly affect quality of life even though the condition is temporary 1, 2
• Identify and remove any causative factors such as medications, physiological stressors, or recent trauma 3

Laboratory Testing Strategy

Selective laboratory testing should be performed only if the clinical picture is atypical or hair loss persists beyond 6 months. 1

Consider the following tests based on clinical presentation:

• Serum ferritin - Iron deficiency is found in 29.5-46.5% of telogen effluvium patients and is the most common nutritional deficiency 4, 5, 6
• TSH and free T4 - Thyroid dysfunction occurs in approximately 4.6% of patients 4
• Vitamin D level - Deficiency is present in 72.2% of screened patients 4, 5
• Zinc level - Deficiency occurs in 2.1% of patients but may be clinically significant 4, 5
• Vitamin B12 and folate - Deficiencies found in 5.8-30.7% and 0.6-4.4% of patients respectively 4, 6

Treatment Algorithm

Step 1: Address Nutritional Deficiencies (if identified)

• Vitamin D supplementation for levels <20 ng/mL according to standard adult dosing recommendations 1, 2
• Iron supplementation if ferritin is low - this is the most frequently prescribed treatment, comprising 37.5% of total prescriptions 1, 4
• Zinc supplementation when deficiency is documented 1
• Vitamin B12 and folate replacement if deficient 4, 6

Step 2: Pharmacologic Treatment (for persistent cases)

For chronic telogen effluvium lasting >6 months despite addressing underlying causes:

• Oral minoxidil (0.25-2.5 mg daily) has shown significant reduction in hair shedding scores, with mean improvement of 1.7 points at 6 months (p<0.001) and 2.58 points at 12 months (p<0.001) 7
• Topical minoxidil may be considered as an alternative, though oral formulation shows more consistent results for diffuse shedding 3, 7
• Corticosteroids may be used in select cases, though evidence is limited for telogen effluvium specifically 3

Step 3: Monitor Response

• Reassess at 3-6 months to evaluate for spontaneous improvement 1
• If hair loss persists beyond 12 months, reconsider the diagnosis 1

Red Flags Requiring Diagnostic Reconsideration

Reconsider the diagnosis if any of the following are present: 1

• Patchy rather than diffuse hair loss
• Scalp erythema, scaling, or induration
• Exclamation mark hairs (suggests alopecia areata)
• Scarring or permanent hair loss
• Hair loss persisting beyond 12 months postpartum (if postpartum telogen effluvium)

Common Pitfalls to Avoid

• Avoid ordering extensive laboratory panels when diagnosis is clinically evident - testing should be targeted based on clinical suspicion 1, 2
• Do not recommend unproven treatments - many supplements and topical products lack evidence for telogen effluvium 1
• Do not overlook the psychological impact - patients may benefit from counseling even though the condition is medically benign 1, 2
• Avoid misdiagnosing diffuse alopecia areata as telogen effluvium - look for characteristic dermoscopic findings like yellow dots and exclamation mark hairs to differentiate 8

Special Considerations

• Trichodynia (scalp pain/tenderness) may accompany telogen effluvium and often improves within 3 months of treatment initiation 7
• Women are more likely to have vitamin D deficiency and should be screened accordingly 4
• Iron deficiency anemia is present in only 6.2% of patients, so low ferritin without anemia is more common and still warrants supplementation 4